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THE  SURGICAL  TREATMENT 

OF 

CHRONIC  SUPPURATION 

OF  THE 

MIDDLE  EAR  AND  MASTOID 


OPPENHEIMER 


A  TYPE  OF  A  NORMAL  TEMPORAL  BONE,  SHOWING  A  PRONOUNCED 
CONVEXITY  OF  THE  MASTOID  PROCESS. 


THELSURGICAL  TREATMENT  OF 
CHRONIC  SUPPURATION  OF  THE 
MIDDLE  EAR  AND  MASTOID"7 


BY 

SEYMOUR  &PPENHEIMER,  M.D. 

Otologist  and  Laryngologist  to  Gouverneur  Hospital;   Otologist  and  Laryngologist  to 

Mount  Sinai  Hospital  Dispensary;  fellow  of  the  American  Laryn- 

gological,  Rhinological  and  Otological  Society,  Etc, 


ILLUSTRATED   BY    FORTY-SIX    HALF-TONE    PLATES    CONTAINING    SIXTY-FOUR    FIGURES   AND 
TWENTY-SEVEN   KEY    PLATES,    ALL   ENGRAVED   FROM   ORIGINAL  DRAWINGS   PRE- 
PARED  FROM   SPECIAL   DISSECTIONS   UNDER   THE  SUPERVISION 
OF   THE  AUTHOR 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &   CO 

IOI2    WALNUT    STREET 
1906 


COPYRIGHT,  1906,  BY  P.  BLAKISTON'S  SON  &  Co. 


Pint  of 

TNI  New  EKA  PRIPITHC  C 
LAUCMTEI,  PA. 


TO 

DR.  JULIUS  RUDISCH 

THIS  VOLUME  IS  DEDICATED  AS  A  TOKEN  OF 
ADMIRATION   AND   RESPECT. 


PREFACE. 

Otological  problems  have  during  the  last  decade  assumed 
a  clearer  aspect,  as  the  result  of  a  better  understanding  of 
morbid  processes  within  the  middle  ear  and  its  communi- 
cating cells.  The  application  of  broad  surgical  antiseptic 
principles  in  the  management  of  suppurative  processes  in 
this  locality  has  greatly  aided  the  study  of  chronic  suppura- 
tive otitis  media  with  its  intracranial  and  mastoidal  compli- 
cations. 

With  the  perfection  of  diagnosis,  much  has  been  done  in 
aiding  the  practitioner  to  take  active  measures  in  order  to 
obtain  the  radical  cure  of  the  suppurating  ear  and  with  the 
conditions  present  in  a  given  case  promptly  recognized  before 
serious  intracranial  or  vascular  changes  have  occurred,  a 
great  step  forward  has  been  taken  in  its  ultimate  cure. 

Special  attention  has  therefore  been  paid  here  to  the  diag- 
nosis of  the  various  morbid  alterations  present  in  this  con- 
dition, as  upon  such  diagnosis,  made  either  previous  or  during 
the  course  of  operation,  will  the  exigencies  of  surgical  treat- 
ment be  based,  whether  this  be  but  the  mere  removal  of  a 
small  particle  of  granulation  tissue  from  the  tympanic  cavity, 


viii  Preface. 

or  the  entire  evisceration  of  the  middle  ear  and  mastoid 
process  with  exposure  of  the  brain  coverings  and  venous 
channels. 

It  has  also  been  desired  to  carry  out  the  plan  of  taking  the 
lesser  conditions  found  in  the  usual  case  of  chronic  aural 
suppuration,  and  from  this  as  a  basis,  gradually  increasing 
the  scope  of  the  pathological  alterations  found  present  and 
the  more  extensive  surgical  treatment,  until  one  reaches  the 
complete  mastoid  operation  with  its  various  modifications, 
and  then  following  this  by  a  description  of  the  plastic  opera- 
tions used  to  aid  in  healing  the  cavity  made  in  the  temporal 
bone  and  also  those  suggested  for  more  or  less  cosmetic 
reasons. 

With  this  plan  in  view  and  at  the  same  time  emphasizing 
the  most  important  features  of  this  monograph,  that  of  the 
surgery  of  chronic  suppurative  otitis  media,  it  is  hoped  that 
it  may  be  of  value  in  at  least  making  clear  some  of  the 
difficult  problems  which  are  constantly  arising  in  the  treat- 
ment of  this  most  important  disease. 

My  sincere  thanks  are  due  my  friend,  Dr.  S.  J.  Kopetzky, 
for  the  painstaking  aid  given  me  in  the  preparation  of  the 
original  dissections  for  the  illustrations. 

S.  O. 

45  EAST  SIXTIETH  STREET,  NEW  YORK, 
December,  1905. 


CONTENTS. 

PART  I. 
CHAPTER    I. 

INTRODUCTORY    5 

CHAPTER   II. 

PRELIMINARY  PREPARATION  OF  THE  PATIENT  FOR  OPERA- 
TION         33 

CHAPTER    III. 

THE  TREATMENT  OF  THE  MUCOSA  AND  MUCO-PERIOSTEUM 

OF   THE   TYMPANIC   CAVITY 41 

CHAPTER    IV. 

THE  TREATMENT  OF  THE  OSSICLES 83 

CHAPTER   V. 

THE  TREATMENT  OF  CARIES  OF  THE  TYMPANIC  WALLS,  THE 

EPITYMPANUM  AND  HYPOTYMPANUM 133 

ix 


x  Contents. 

CHAPTER   VI. 

THE    AFTER-TREATMENT    OF    OPERATIONS    THROUGH    THE 

EXTERNAL  AUDITORY  CANAL 155 


PART  II. 
CHAPTER   I. 

ANATOMICAL  AND   SURGICAL  LANDMARKS 179 

CHAPTER    II. 

PRELIMINARY  PREPARATION  OF  THE  PATIENT  FOR  OPERA- 
TION      227 

CHAPTER   III. 

THE   SIMPLE  MASTOID   OPERATION 235 

CHAPTER    IV. 

THE  RADICAL   MASTOID   OPERATION 277 

CHAPTER   V. 

MODIFICATIONS   OF   MASTOID   OPERATIONS 323 

CHAPTER   VI. 

THE  RETRO-AURICULAR  OPENING  AND  PLASTIC  METHODS.. .  343 

CHAPTER   VII. 

THE  AFTER-TREATMENT  OF  MASTOID  OPERATIONS 391 

INDEX    .  411 


LIST  OF  ILLUSTRATIONS. 

PLATE.  PAGE. 

I.  The  relations  of  the  facial  nerve  to  the  ossicles,  and 

the  attic  to  the  cerebral  fossa 12 

II.  The  position  of  the  drum  membrane  and  its  relations 

to  the  osseous  auditory  canal 16 

III.  The  external  auditory  canal  with  the  contents  of  the 

tympanic  cavity  exposed 24 

IV.  The  relations  of  the  facial  nerve  and  foot  plate  of  the 

stapes.    Also  the  tympanic  opening  of  the  Eustachian 

tube 28 

V.  View   of   the   tympanic   cavity   showing   a   retracted 

cicatrix 48 

VI.  View  of  the  tympanic  cavity  showing  an  adhesive 
process  between  the  drum  membrane  and  pro- 
montory    50 

VII.  View  of  the  tympanic  cavity  illustrating  the  cutting 

of  adhesions 52 

VIII.  A  normal  drum  membrane;  a  retracted  drum  mem- 
brane ;  capillary  congestion  of  the  drum  membrane ; 


xii  List  of  Illustrations. 

PLATE.  PAGE- 

effusion  behind  the  drum  membrane  before  and  after 
inflation;  an  oval-shaped  perforation  of  the  drum 

membrane 60 

IX.  Multiple  and  healed  perforations  of  the  drum  mem- 
brane    64 

X.  Perforations  of  the  drum  membrane,  ossicular  necrosis, 

and  polypi  7° 

XI.  Ossicular  necrosis  and  calcareous  deposits 76 

XII.  Caries  of  the  ossicles 90 

XIII.  Caries  of  the  ossicles 94 

XIV.  The  removal  of  the  malleus no 

XV.  The  removal  of  the  incus 116 

XVI.  Necrosis  of  the  malleus  and  polypus 122 

XVII.  Necrosis  of  the  osseous  canal  wall,  absence  of  the  incus 

and  stapes,  and  perforation  of  the  drum  membrane.  138 

XVIII.  A  type  of  normal  temporal  bone 184 

XIX.  Sagittal  section  of  the  mastoid  process  and  tympanic 
cavity,  showing  the  relations  of  its  nerves,  muscles 

and  ossicles 188 

XX.  The  course  of  the  carotid  artery  through  the  petrous 

portion  of  the  temporal  bone 194 

XXI.  The  internal  surface  of  the  temporal  bone  exposing  the 

internal  ear  198 

XXII.  External  surface  of  the  temporal  bone  of  the  infant. .  204 

XXIII.  Internal  surface  of  the  temporal  bone  of  the  infant. . .  210 

XXIV.  Cross  section  of  a  temporal  bone  of  the  pneumatic  type.  214 
XXV.  Cross  section  of  a  temporal  bone  of  the  diploic  type . .  220 

XXVI.  The  primary  retro-auricular  incision 246 

XXVII.  The  primary  incision  carried  down  to  the  bone  expos- 
ing the  field  of  operation 250 


List  of  Illustrations.  xiii 

PLATE.  PAGE. 

XXVIII.  The  external  cortex  of  the  mastoid  removed  and  the 

antrum  opened   256 

XXIX.  The  completed  simple  mastoid  operation 266 

XXX.  The  completed  radical  mastoid  operation 284 

XXXI.  The  course  of  the  facial  nerve  in  its  bony  canal  and 

its  relations  to  the  tympanic  cavity 300 

XXXII.  The  completed  radical  mastoid  operation  with  an  ex- 
posure of  the  sigmoid  sinus  and  the  middle  cerebral 
fossa  316 

XXXIII.  The  incisions  for  making  the  Koerner  flap 350 

XXXIV.  The  completed  Koerner  flap 352 

XXXV.  The  first  incision  in  the  Jansen  modification  of  the 

Stacke  flap  operation 356 

XXXVI.  The  second  step  in  the  Jansen  modification  of  the 

Stacke  flap  operation 358 

XXXVII.  The  second  incision  in  the  Jansen-Stacke  flap  opera- 
tion      360 

XXXVIII.  The  completed  Jansen-Stacke  flap  operation 362 

XXXIX.  The  first  step  in  the  Passow-Trautman  plastic  opera- 
tion     370 

XL.  The  second  step  in  the  Passow-Trautman  plastic  opera- 
tion      372 

XLI.  The  completed  Passow-Trautman  plastic  operation . . .   374 
XLII.  The  first  step  in  the  Mosetig-Moorhof  plastic  opera- 
tion   378 

XLIII.  The    second    step    in    the    Mosetig-Moorhof    plastic 

operation 380 

XLIV.  The  third  step  in  the  Mosetig-Moorhof  plastic  opera- 
tion      382 

XLV.  The  completed  Mosetig-Moorhof  plastic  operation. . . .   384 


PART  I. 

OPERATIONS  THROUGH  THE 

EXTERNAL  AUDITORY 

CANAL 


CHAPTER  I. 

INTRODUCTORY. 


INTRODUCTORY. 

When  a  chronic  suppurative  otitis  media  does  not  respond 
to  the  varied  forms  of  local  treatment  and  topical  applica- 
tions commonly  in  use,  after  long  and  persistent  care,  the 
question  in  a  certain  proportion  of  such  cases  will  arise  as 
to  the  advisability  of  surgical  treatment  and  whether  the 
pathological  conditions  present  in  the  individual  case,  indi- 
cate the  removal  of  the  altered  tissues  through  the  external 
auditory  canal  or  by  the  more  extensive  mastoid  operation 
in  its  simplest  form,  or  its  complicated  and  varied  modi- 
fications up  to  the  complete  so-called  radical  operation  or 
evisceration  of  the  mastoid  and  tympanic  contents. 

The  object  of  operative  procedures  by  way  of  the  audi- 
tory canal  is  primarily  to  secure  free  drainage  and  to  remove 
necrotic  and  carious  tissue  when  such  is  present  in  the  tym- 
panic cavity  in  limited  and  easily  accessible  areas,  thus  often 
removing  parts  of  the  auditory  conducting  mechanism  and 
at  the  same  time  carrying  out  the  well  known  surgical  prin- 
ciple of  removing  obstructions  to  the  thorough  evacuation 
of  purulent  collections.  By  these  means  provided  the  tym- 
panic focus  of  infection  is  limited  and  available  to  such 

5 


6  Suppuration  of  the  Middle  Ear. 

instrumentation,  the  causes  which  keep  up  the  discharge  are 
removed  with  the  elimination  of  the  diseased  bone  and  the 
surgical  cleanliness  which  may  then  be  obtained.  In  addi- 
tion to  removing  the  necrotic  tissue  and  carious  bone,  another 
object  obtained  is  the  prevention  of  marked  mastoid  changes, 
especially  by  extracting  the  malleus,  incus  and  curetting  the 
tympanic  cavity  and  thus  by  securing  free  drainage  with 
added  facilities  for  ingress  to  the  heretofore  inaccessible  parts 
lying  above  and  behind  these  ossicles.  Ludewig,  with  many 
others,  claims  that  in  this  way  the  mastoid  operation  can 
often  be  avoided  and  in  100  such  cases  which  he  reports,  80 
per  cent,  were  cured  of  the  suppuration,  while  with  no 
untoward  results  as  regards  facial  paralysis  he  was  able 
to  secure  in  75  of  the  series  an  improvement  in  hearing — an 
added  factor  of  importance. 

In  addition  to  the  removal  of  the  ossicles  and  curetting 
the  granulation  tissue  usually  present,  one  is  often  enabled 
to  obtain  a  permanent  cure  by  removing  a  part  of  the 
necrosed  Rivinian  segment  with  curette,  or,  better,  the  for- 
ceps chisel,  while  in  another  group  of  cases  the  object  of  this 
operation  through  the  external  canal  is  in  addition  to  remov- 
ing the  cause  of  the  continued  suppuration,  the  relief  of 
more  serious  symptoms  of  a  septicaemic  nature  as  shown 
by  oscillations  in  the  temperature  or  continued  temperature 
slightly  above  the  normal  and  indicative  of  the  accumula- 
tion or  retention  of  purulent  debris.  In  selected  cases  of 
chronic  suppuration  persisting  in  spite  of  ordinary  non- 
operative  measures,  intratympanic  operation  is  undoubtedly 
most  promising  and  is  also  remarkably  free  from  risk  either 
to  the  patient  or  his  hearing.  While  it  must  be  borne  in 
mind  that  in  practically  all  cases  of  long  standing,  diseased 
bone  is  always  present,  yet  when  the  carious  areas  are  con- 
fined to  the  two  larger  ossicles  or  parts  of  the  tympanic 
walls  accessible  through  the  canal,  excision  and  curettage 


Introductory.  7 

presents  an  almost  ideal  form  of  operation,  as  its  perform- 
ance is  comparatively  simple  and  safe  and  in  a  large  per- 
centage of  such  cases  a  permanent  cure  may  be  confidently 
expected.  Further  than  this,  it  presents  the  advantages  of 
requiring  no  external  wound,  does  not  keep  the  patient  inca- 
pacitated for  any  length  of  time  as  does  the  mastoid  opera- 
tion and  in  occasional  cases  as  will  be  more  fully  mentioned 
later,  local  instead  of  general  anaesthesia  alone  may  be 
required. 

The  essentials  for  successful  results  in  ossiculectomy 
depend  of  necessity  upon  many  factors,  and  while  it  is  nec- 
essary as  general  principles  to  perfect  thorough  cleanliness, 
with  perfect  drainage  and  the  removal  of  all  diseased  tissue 
as  far  as  possible  from  the  tympanic  cavity,  yet  the  careful 
selection  of  cases  in  which,  as  far  as  can  be  determined,  the 
suppuration  is  limited  to  the  ossicular  chain  or  its  immediate 
vicinity,  or  cases  in  which  the  presence  of  marked  choles- 
teatoma  can  be  excluded,  is  requisite.  A  certain  proportion 
of  failures  of  necessity  will  occur  even  under  such  circum- 
stances, and  it  is  always  advisable  when  this  operation  is 
indicated  and  has  been  urged  upon  the  patient,  to  fully  state 
to  him  that  while  the  diseased  tissue  may  be  removed  and 
the  suppuration  cured,  yet  such  cannot  be  confidently  prog- 
nosticated and  is  not  always  sure  on  account  of  hidden  and 
inaccessible  foci  of  caries,  which  may  at  a  subsequent  date 
render  a  mastoid  operation  necessary.  Unless  the  condi- 
tion of  the  external  auditory  canal  permits,  even  with  appar- 
ent indications  for  ossiculectomy  present,  it  will  be  impos- 
sible to  succeed  until  the  canal  has  been  suitably  treated  or 
is  of  sufficient  width  to  allow  of  the  introduction  of  the 
instruments.  It  is  therefore  essential  that  a  low  grade 
stenosis  or  fibrous  atresia  of  the  canal  be  relieved  before 
such  operative  procedures  can  be  performed  and  in  case  this 
is  not  possible,  the  mastoid  operation  will  become  a  necessity 


8  Suppuration  of  the  Middle  Ear. 

in  order  to  reach  the  middle  ear.  In  old  otorrhceas  which 
have  not  received  proper  attention,  it  is  not  infrequently  the 
case  that  the  canal  in  part  or  its  greater  entirety,  is  found  to 
be  filled  with  exuberant  granulation  tissue  and  of  course 
this  must  be  removed  previous  to  any  intratympanic  opera- 
tion. Careful  antiseptic  cleansing  for  some  time  in  advance 
will  often  greatly  aid  in  reducing  the  granulation  tissue,  but 
often  it  becomes  necessary  to  remove  the  growth  with  snare, 
curette  or  cautery,  not  only  to  obtain  available  working 
space,  but  it  is  also  highly  important  to  remove  as  far  as 
possible  anything  which  will  add  to  the  bleeding  and  thus 
obscure  the  field  of  vision.  After  the  canal  has  been  restored 
to  a  fairly  normal  condition,  it  will  then  become  possible  to 
attack  the  affected  tissues  causing  the  suppuration.  Should 
no  fistulous  openings  be  found  along  the  walls  of  the  canal 
or  in  Shrapnell's  membrane  and  the  location  of  the  aural 
discharge  be  somewhat  obscure,  it  may  be  almost  taken  for 
granted  in  a  not  inconsiderable  number  of  cases,  that  the 
pathological  changes  are  situated  somewhere  in  the  upper 
and  posterior  portion  of  the  middle  ear  and  careful  probing 
after  the  parts  are  cleansed  with  a  fine  cannula  and  syringe, 
will  usually  disclose  the  existence  of  granulation  tissue,  lim- 
ited areas  of  caries  and  epithelial  and  cheesy  debris.  An 
additional  point  of  considerable  importance  in  ascertaining 
the  anatomical  landmarks  within  the  middle  ear  for  diag- 
nostic and  operative  purposes,  careful  note  should  be  made 
in  the  individual  case  of  the  axis  of  the  external  auditory 
canal  in  relation  to  the  horizontal  plane  of  the  head  and 
especially  so  if  the  patient  is  in  the  recumbent  position,  since 
in  this  way  only  can  be  obtained  a  fairly  accurate  criterion 
of  the  relative  location  of  the  tympanic  contents. 

In  relation  to  operative  procedures,  one  should  always 
bear  in  mind  a  fact  that  is  so  often  forgotten,  namely,  that 
the  purulent  discharge  should  be  looked  upon  as  a  symptom 


Introductory.  9 

of  the  pathological  conditions  present  and  not  as  the  actual 
disease  itself.  The  presence  of  the  suppuration  indicates 
either  the  presence  of  granulation  tissue  or  polypi;  choles- 
teatoma  formation;  the  retention  and  possible  caseation  of 
pus  in  inaccessible  parts  of  the  tympanum  or  accessory  cavi- 
ties or  in  loculi  and  depressions  of  the  bony  walls ;  or  it  often 
implies  a  carious  process  in  the  middle  ear  and  in  relation 
to  this  it  is  sometimes  kept  up  by  a  chronic  inflammation  of 
the  external  auditory  canal  or  by  morbid  tissue  changes  of 
varying  sorts  in  the  nasal  chambers  or  nasopharynx.  Irre- 
spective of  these  conditions  but  closely  associated  with  them, 
the  otorrhcea  may  at  times  be  simply  the  result  of  a  deficient 
tissue  vitality,  or  an  increased  microorganismal  potency ;  the 
operative  results  in  such  cases  being  greatly  enhanced  by 
preliminary  treatment  directed  towards  stimulating  and 
increasing  the  nutrition  of  the  affected  tissues  and  also  by 
such  measures  as  will  lessen  the  activity  of  the  particular 
organisms  present.  The  odor  of  the  discharge  can  rarely 
be  relied  upon  as  an  indication  of  necrosed  bone  unless  it  is 
unusually  persistent  following  careful  local  cleansing  of  the 
tympanic  cavity,  when  in  the  absence  of  other  symptoms, 
such  a  condition  may  be  suspected  although  more  often  it 
implies  the  presence  of  a  retained  irritating  secretion  or  of 
a  mass  of  desquamated  epithelium  undergoing  fatty  trans- 
formation. When  such  a  discharge  is  persistent,  however, 
it  may  indicate  retained  decomposition  products  which  can- 
not be  reached  by  way  of  the  canal,  necessitating  recourse 
to  a  more  extensive  operation,  especially  if  the  discharge 
should  cease  for  a  time  and  again  recurring  at  intervals  of 
a  few  weeks  or  even  months,  should  be  preceded  by  pain  and 
examination  should  reveal  the  presence  of  a  perforation  in 
the  flaccid  membrane  with  extensive  changes  in  the  region 
of  the  attic. 

While  it  is  not  desired  or  even  contemplated  here  to 


io  Suppuration  of  the  Middle  Ear. 

describe  the  anatomy  of  this  region,  yet  it  is  required  to 
mention  certain  points,  the  knowledge  of  which  are  essen- 
tial to  the  successful  performance  of  intratympanic  opera- 
tions, and  also  to  emphasize  the  necessity  of  the  thorough 
realization  to  the  otologist  of  the  finer  and  detailed  anat- 
omical landmarks  as  especially  related  to  the  surgical  path- 
ology of  this  region.  Usually  for  purposes  of  localization, 
the  membrana  tympani  is  divided  into  the  four  well  known 
segments,  but  Fougeray  has  found  it  of  more  service  to 
divide  the  drum  head  into  but  two  parts,  by  an  imaginary 
line  horizontally  placed  and  passing  almost  over  the  round 
window.  For  intratympanic  study  as  concerns  us  here  this 
is  quite  practicable,  and  if  one  will  carefully  examine  an 
ear  with  this  in  mind,  it  will  be  found  that  practically  all  the 
important  structures  are  placed  above  this  line.  It  is  essen- 
tial in  this  connection,  however,  to  realize  that  the  angle 
formed  by  the  manubrium  and  this  horizontal  line  varies  in 
different  positions  of  the  head.  As  far  as  the  tympanic 
cavity  itself  is  concerned,  it  is  best  to  consider  it  as  consist- 
ing of  three  parts  exclusive  of  the  accessory  cavities;  the 
superior  portion  of  attic  being  bounded  inferiorly  by  the 
tendon  of  the  tensor  tympani  muscle  and  the  facial  canal  in 
its  horizontal  portion,  and  containing  the  body  of  the  incus 
and  the  head  of  the  malleus.  Further  than  this,  the  epitym- 
panic  space  may  be  described  as  that  portion  of  the  tympa- 
num superior  to  a  horizontal  line  passing  through  the  short 
process  of  the  malleus.  The  tegmen  (see  plate  I)  is  situated 
a  short  distance  above  the  annulus,  giving  attachment  to  the 
membrana  tympani,  and  it  is  important  to  bear  in  mind  in 
every  case  of  chronic  suppuration  that  the  tympanic  roof  is 
not  always  intact,  both  on  account  of  irregular  dehiscences 
which  occur  in  this  position  and  also  on  account  of  the  petro- 
squamous  suture,  which  is  sometimes  so  incompletely  closed 
at  this  point  that  an  intimate  relation  amounting  to  almost 


EXPLANATORY    NOTE    TO    PLATE    I. 


An  original  anatomical  section  showing  the  relations  of  the  facial  nerve  to  the 
ossicles  and  the  relations  of  the  attic  and  its  contents  to  the  cerebral  fossa.  The 
tegmen  tympani  is  noticed  as  being  exceptionally  thin. 

i,  Tegmen  tympani ;  2,  ossicles  and  attic ;  3,  drum  membrane ;  4,  external  auditory 
canal ;  5,  mastoid  cells  which  have  been  excavated ;  6,  facial  nerve  exposed ;  7,  mar- 
ginal rim  of  drum  membrane ;  8,  aquaeductus  Fallopii. 

12 


PLATE  I 


Introductory.  13 

close  contact  of  the  dura  mater  and  tympanic  mucous  mem- 
brane is  permitted.  The  external  wall  of  this  portion  of  the 
tympanum  is  composed  in  part  of  the  flaccid  membrane 
and  a  large  part  of  the  osseous  wall,  the  pars  ossea. 

The  atrium  or  middle  portion  of  the  tympanic  cavity 
embraces  that  part  lying  internally  to  the  membrana  tympani 
and  its  bony  supporting  wall,  and  while  it  does  not  possess 
the  same  surgical  importance  as  the  attic,  the  ofttimes  ex- 
treme thinness  of  its  labyrinthine  or  inner  wall  suggests  the 
precaution  of  great  care  in  removing  granulation  tissue  or 
necrotic  areas  from  its  surface.  The  atrium  is  separated 
from  the  tympanic  vault  by  the  body  and  neck  of  the  malleus, 
the  anterior  and  external  ligaments  and  the  numerous  redu- 
plications of  the  mucous  membrane.  The  latter  often  is 
so  thrown  into  folds  and  reduplications  that  the  upper  cham- 
ber is  so  completely  shut  off  from  the  lower,  that  even  air 
cannot  pass  from  one  to  the  other ;  this  factor  being  of  great 
importance  in  chronic  suppurative  processes.  It  is  here 
in  the  upper  portion  of  the  flaccid  membrane  that  we  occa- 
sionally find  a  perforation  communicating  with  one  of  these 
mucous  pockets  just  above  the  short  process,  or  slightly  pos- 
terior to  it,  or  still  more  infrequently  above  the  anterior  liga- 
ment. The  floor  of  the  tympanum  or  hypotympanic  space 
is  situated  below  and  behind  the  inferior  border  of  the 
sulcus  tympanicus  and  in  front  is  in  close  proximity  to  the 
internal  carotid  artery,  while  posteriorly  it  bears  a  similar 
close  relation  to  the  jugular  fossa.  (See  plate  II.) 

As  a  result  of  the  morbid  changes  which  take  place,  it 
is  often  difficult  to  accurately  localize  the  ossicular  land- 
marks ;  this  is  especially  so  when  a  portion  of  the  manubrium 
has  been  destroyed  by  caries,  so  that  it  appears  as  if  worn 
away  to  a  stump  ending  suddenly  below  the  short  process, 
or  again,  it  may  have  an  irregular  appearance  and  show  a 
sharp  point.  The  short  process  of  the  malleus  is  by  far  the 


14  Suppuration  of  the  Middle  Ear. 

most  important  landmark  to  be  first  sought  out,  as  it  usually 
remains  in  its  normal  position,  and  from  it  as  a  basis  the 
manubrium  can  be  located,  even  as  is  commonly  found  that 
this  portion  of  the  malleus  is  necrosed  so  that  it  is  drawn 
inwards  or  upwards  by  fibrous  bands,  or  even  partially 
obscured  from  view  by  the  thickened  anterior  and  posterior 
folds,  or  by  an  unusually  prominent  short  process.  Val- 
uable information  may  be  ordinarily  obtained  from  the  char- 
acter and  anatomical  location  of  the  perforation  in  the  mem- 
brana  tympani  and  especially  by  the  study  of  the  perforation 
when  located  in  the  flaccid  portion  of  this  membrane  where 
it  is  almost  invariably  indicative  of  necrosis  of  the  malleus 
and  ofttimes  of  the  incus.  As  has  been  shown  by  Politzer, 
perforation  of  Shrapnell's  membrane  is  produced  in  the 
majority  of  cases  by  the  inflammation  involving  the  entire 
middle  ear,  while  later  it  may  be  localized  only  to  the  external 
attic.  In  these  cases  there  are  often  present  adhesions  be- 
tween the  membrana  tympani  and  the  inner  tympanic  wall, 
this  being  strongly  suggestive  of  antral  suppuration.  The 
perforation  may  be  in  almost  any  part  of  this  membrane, 
but  it  is  more  frequently  central  and  the  neck  of  the  malleus 
may  be  exposed,  the  vessels  in  the  neighborhood  of  the  short 
process  and  the  handle  of  the  malleus  are  injected,  while  as 
the  result  of  an  encapsulated  pus  collection,  Prussak's  space 
may  be  filled  and  the  posterior  segment  of  the  membrana 
tympani  may  be  bulging  into  the  lumen  of  the  canal.  The 
local  septic  condition  thus  produced  by  the  encapsulation  of 
cholesteatomatous  material  or  pus  cells  in  one  of  these 
numerous  mucous  membrane  folds,  leads  to  destruction  not 
only  of  a  portion  of  the  ossicular  chain,  but  also  to  parts  of 
the  osseous  walls  adjacent  to  the  segment  of  Rivinius,  thus 
producing  defects  of  the  osseous  continuity  of  the  upper  wall 
of  the  auditory  canal.  These  defects  when  present  vary  in 
size  from  that  of  a  pin  head  to  a  gap  above  the  short  process, 


EXPLANATORY    NOTE    TO    PLATE    II. 


An  original  anatomical  section  showing  the  position  of  the  drum  membrane  and 
its  relations  to  the  osseous  auditory  canal.  The  tympanic  cavity  is  opened  laterally. 

i,  Membrana  tympani,  with  malleus;  2,  osseous  auditory  canal  opened;  3, 
tympanic  cavity  opened  exposing  the  promontory ;  4,  acute  (lower)  angle  formed  by 
the  drum  membrane  with  the  floor  of  the  auditory  canal ;  5,  carotid  canal ;  6,  tegmen 
tympani ;  7,  obtuse  (upper)  angle  formed  by  the  drum  membrane  with  the  auditory 
canal. 

16 


PLATE  II 


Introductory.  17 

exposing  a  great  part  of  the  attic,  after  the  purulent  secre- 
tion, epithelial  masses  or  granulations  which  usually  fill  it, 
have  been  removed. 

In  cases  that  have  resisted  the  usual  local  treatment,  but 
in  which  the  suppuration  continues  without  apparent  exten- 
sion of  the  morbid  process  to  any  marked  degree,  the  per- 
foration in  the  membrana  flaccida  indicates  serious  attical 
changes  in  the  nature  of  partial  ossicular  caries  or  caries 
of  the  attical  walls,  with  often  retained  pus,  granulation 
tissue  and  cholesteatoma.  These  cases  may  be  relieved  or 
even  cured  in  some  instances  by  removing  the  remains  of 
the  tympanic  membrane  and  larger  ossicles,  with,  in  some 
cases,  excision  of  the  outer  attic  wall.  Posterior  perfora- 
tions of  the  membrana  tympani  are  usually  attended  with 
considerable  discharge  remaining  unchanged  in  amount  after 
long  treatment  and  often  accompanied  with  a  marked  degree 
of  impairment  of  hearing.  They  are  significant  often  of 
caries  of  the  incus,  especially  of  its  articular  process  and 
the  perforation  may  extend  in  such  a  direction  either  supe- 
riorly or  inferiorly,  that  the  head  of  the  stapes  can  be 
readily  recognized.  Perforations  of  the  anterior  segment 
of  the  membrana  tympani  seem  to  be  usually  associated  with 
a  more  profuse  purulent  discharge  than  is  found  with  per- 
forations in  other  parts,  and  they  are  also  found  most  fre- 
quently in  a  group  of  cases  in  which  the  tympanic  suppu- 
ration bears  an  intimate  relation  with  catarrhal  changes  in 
the  Eustachian  tube  (see  plate  IV),  nasopharynx  and  nasal 
chambers.  In  these  cases,  caries  of  the  tip  of  the  manu- 
brium  is  often  associated,  which  does  not  necessarily  require 
surgical  treatment,  nor  is  excision  of  the  ossicles  demanded 
in  this  group  as  frequently  as  when  the  perforation  is  situated 
elsewhere,  as  when  there  is  retention  of  the  decomposed 
products  of  purulent  formation,  a  fair  percentage  show  a 

3 


1 8  Suppuration  of  the  Middle  Ear. 

permanent  cure  under  antiseptic  treatment  with  incision  of 
the  membrana  sufficient  to  obtain  good  drainage. 

According  to  Leutert  who  has  made  some  valuable  obser- 
vations relative  to  the  surgical  importance  of  tympanic  mem- 
brane perforations,  the  surgeon  must  determine  the  seat  of 
suppuration  in  the  tympanum  and  also  as  to  the  presence 
or  absence  of  diseased  bone.  He  classes  these  cases  of 
chronic  suppurative  otitis  media  under  four  headings:  Sup- 
puration of  the  middle  ear;  suppuration  of  the  Eustachian 
tube  and  nasopharynx;  suppuration  of  the  attic;  and  sup- 
puration of  the  antrum.  As  regards  the  presence  or  absence 
of  diseased  bone  in  the  middle  ear,  the  discharge  may  be 
associated  with  disease  of  the  ossicles  or  with  disease  of  the 
bony  walls  of  the  drum  cavity  and  he  claims  it  is  possible 
to  recognize  this  by  the  position  of  the  perforation  in  the 
membrana  tympani.  When  the  perforation  is  in  the  pos- 
terior upper  quadrant,  it  indicates  isolated  caries  of  the  long 
limb  of  the  incus ;  if  it  is  in  the  flaccid  membrane  and  extends 
to  the  periphery,  it  shows  that  there  is  caries  of  the  roof  of 
the  antrum,  the  posterior  wall  of  the  antrum  and  the  inner- 
most part  of  the  posterior  wall  of  the  external  auditory  canal. 
Should  the  perforation  involve  the  flaccid  membrane  directly 
above  the  short  process,  one  would  be  led  to  suspect  caries 
of  the  head  of  the  malleus,  and  if  it  is  behind  the  short 
process,  it  indicates  caries  of  the  incus;  while  if  not  entirely 
in  the  membrane  but  also  extends  into  the  osseous  wall  of 
the  attic,  it  shows  that  there  is  a  carious  condition  of  the 
head  of  the  malleus;  when  this  perforation  in  the  bone  ex- 
tends backwards,  both  the  malleus  and  incus  are  carious, 
with  a  probable  implication  of  the  antrum.  When  there 
remains  some  peripheral  remnants  of  the  membrana  tympani 
with  the  handle  of  the  malleus  projecting  free  into  the  tym- 
panic cavity,  there  is  probably  an  absence  of  caries  of  the 
incus,  as  drainage  is  free  and  retention  of  pus  does  not  take 


Introductory.  19 

place.  When  the  perforation  is  found  in  the  lower  ante- 
rior quadrant,  the  carious  area  is  in  the  same  position  on 
the  tympanic  wall  and  in  those  cases  where  the  perforation 
reaches  to  the  anterior  periphery  about  the  middle  of  the 
drum,  the  Eustachian  tube  plays  a  prominent  part  in  the 
suppurative  process.  With  caries  of  the  anterior  part  of 
the  attic  not  involving  the  ossicles,  the  perforation  will  be 
in  the  periphery  of  the  tympanic  membrane  and  extending 
to  the  anterior  attical  wall,  and  when  the  perforation  is  in 
the  lower  segment  of  the  membrana  tympani  but  not  extend- 
ing to  the  periphery,  one  can  exclude  extensive  disease  of 
the  cavities  adjacent  to  the  tympanum.  The  perforations 
which  do  not  involve  the  periphery  of  the  lower  portion  of 
the  tympanic  membrane,  are  characteristic  of  isolated  sup- 
puration in  the  drum  cavity  and  an  operation  on  the  ossicles 
is  usually  contraindicated,  as  it  will  not  expose  the  focus 
of  the  disease  and  in  this  group  it  is  only  those  cases  where 
the  perforation  is  peripheral,  that  is,  when  the  disease  is 
located  on  the  postero-superior  or  antero-inferior  wall  of 
the  tympanic  cavity,  that  operation  through  the  canal  will 
expose  the  infected  focus  to  direct  treatment,  and  it  should 
also  be  remembered  in  these  cases  that  the  treatment  should 
be  most  conservative. 

Closely  associated  with  the  pathological  alterations  of 
the  middle  ear  and  playing  a  prominent  part  in  the  results 
obtained  by  operation  through  the  auditory  canal,  is  the 
tympanic  mucous  membrane,  which  also  plays  the  part  of 
a  periosteum  especially  to  the  ossicles  which  entirely  derive 
their  nutrition  through  its  vessels  and  when  by  changes  in 
the  periosteum  this  is  diminished  or  entirely  abolished,  caries 
inevitably  takes  place.  The  retention  of  pus  by  the  numer- 
ous folds  of  the  mucosa  is  also  of  considerable  surgical  im- 
portance, but  it  is  desired  only  to  mention  briefly  these  facts 
here,  as  they  will  be  treated  of  later  in  greater  detail. 


20  Suppuration  of  the  Middle  Ear. 

The  inner  tympanic  wall  is  of  great  importance.  Con- 
siderable variation  of  opinion  exists  as  to  whether  it  should 
be  left  undisturbed  in  the  event  of  gross  pathological  changes 
of  its  mucosa  on  account  of  the  supposed  danger  to  the 
important  labyrinthine  structures  which  it  separates  from 
the  tympanic  cavity,  or  whether  it  should  be  curetted  from 
the  same  as  other  portions  of  this  chamber,  when  such 
measures  seem  to  be  apparently  indicated,  equally  good 
authorities  on  both  sides  of  this  question  being  in  favor  of 
such  measures,  while  others  are  strongly  opposed  to  it.  It 
seems,  however,  that  with  the  exercise  of  due  care  and  with 
regard  to  the  landmarks  upon  it,  there  are  no  good  rea- 
sons why  diseased  tissue  should  not  be  removed  from  here 
as  well  as  from  any  other  parts  of  the  tympanic  cavity,  and 
one  can  hardly  appreciate  the  view  that  a  mass  of  exuberant 
granulation  tissue  should  be  allowed  to  remain,  when  it 
jeopardizes  the  entire  results  of  an  otherwise  successful 
intratympanic  operation.  On  account  of  the  comparative 
frequency  of  natural  or  pathological  dehiscences  of  the 
tympanic  roof,  great  caution  should  be  exercised  in  any 
manipulations  here  during  the  removal  of  the  ossicles  or 
curetting  the  walls  of  the  tympanum,  for  if  one  should  pene- 
trate to  the  dura  under  such  circumstances,  a  fertile  field 
for  infection  will  be  opened  up,  and  what  was  a  compara- 
tively benign  operative  procedure,  will  necessitate  a  more 
formidable  opening  of  the  broken  down  area  to  possibly  pre- 
vent an  infective  intracranial  process  taking  place.  The 
surgical  relations  of  the  roof  of  the  tympanum  are  therefore 
of  great  importance,  as  it  is  formed  by  the  petrosquamous 
suture  and  with  the  vault  of  the  antrum  is  in  close  relation 
with  the  middle  cranial  fossa  and  the  former  especially  sup- 
ports in  front  the  temporosphenoidal  lobe  of  the  cerebrum. 

The  relations  of  the  attic  (see  plate  III)  both  to  the  tym- 
panum proper  and  to  the  aditus  and  antrum,  make  it  essential 


Introductory.  21 

in  the  majority  of  cases  of  chronic  suppuration  which  come  to 
operation,  that  free  drainage  be  thoroughly  effected.  There 
is  a  small  group  of  cases  in  which  varied  signs  point  to  a  gen- 
eral mastoid  sclerosis,  yet  radical  operation  is  apparently  not 
indicated  and  in  instances  of  this  nature,  the  drainage  of  the 
attic  should  be  obtained  by  the  excision  of  the  membrana  tym- 
pani,  ossicles  and  such  granulation  tissue  that  may  be  present. 
Another  group  which  is  not  infrequent,  shows  evidences  of 
a  limitation  of  the  residual  suppurating  process  to  the  attic 
or  epitympanic  space  and  in  such  cases  great  difficulty  may 
be  experienced  in  locating  the  minute  perforation  which  is 
always  found  in  the  membrana  flaccida.  The  purulent  dis- 
charge is  often  a  mere  suspicion  of  moisture,  just  sufficient 
to  annoy  the  patient.  As  a  result  of  its  scant  quantity  it 
rapidly  dries  and  forms  crusts  in  the  immediate  vicinity  of 
the  perforation  in  the  superior  quadrant  of  the  membrana 
and  neighboring  wall  of  the  canal.  A  drop  of  partially 
inspissated  pus  may  sometimes  be  discovered  covering  the 
perforation,  or  again  a  minute  polypus  may  seem  to  be  emerg- 
ing through  it  and  lead  to  the  belief  that  the  polyp  forma- 
tion is  probably  single,  when  further  search,  especially  after 
removing  a  portion  of  Shrapnell's  membrane  or  enlarging 
the  perforation,  will  reveal  the  attic  filled  with  granulation 
tissue. 

When  these  cases  are  seen  quite  late,  that  is,  after  they 
have  existed  for  a  long  period  of  time,  the  larger  part  of  the 
tympanic  cavity  seems  to  be  free  from  any  evidences  of 
active  pathological  processes,  although  the  alterations  in  the 
mucous  membrane  especially,  clearly  signify  the  existence 
of  previously  active  suppurative  changes,  the  existent  attical 
suppuration  to  all  intents  being  the  residual  localization  of 
the  affection.  As  the  epitympanic  recess  is  in  major  part 
partitioned  off  from  the  body  of  the  tympanum  proper  even 
in  the  natural  state  by  the  irregularly  placed  and  horizontal 


22  Suppuration  of  the  Middle  Ear. 

reduplications  of  the  tympanic  mucous  membrane  and  por- 
tions of  the  two  larger  ossicles  with  their  ligaments  which 
bring  them  into  close  association  with  the  osseous  walls  of 
the  cavity  and  these  structures  combined  form  a  definite 
floor  for  the  attical  space,  it  can  readily  be  appreciated  that 
although  a  part  of  the  tympanic  cavity,  yet  from  a  surgical 
aspect  it  is  in  great  part  distinct  and  as  such,  should  be  con- 
sidered more  in  the  light  of  an  accessory  chamber.  Under 
such  circumstances,  the  hyperplastic  changes  which  take 
place  in  the  structures  forming  its  floor  after  the  disease  has 
continued  for  a  length  of  time,  necessarily  renders  it  prac- 
tically an  isolated  cavity  and  when  epithelial  debris  or  puru- 
lent material  is  retained  here,  the  drainage  is  entirely  impos- 
sible by  natural  means  and  unless  relieved  by  operation 
through  the  canal,  will  produce  an  extension  of  the  morbid 
changes  posteriorly  through  the  antrum  into  the  mastoid 
cells.  In  practically  all  cases  at  this  stage,  the  antrum  and 
adjacent  mastoid  regions  are  involved  to  some  extent,  but 
rarely  to  the  degree  necessitating  a  mastoid  operation  and  in 
a  lesser  number  of  cases,  the  perforation  in  the  flaccid  mem- 
brane increases  in  size  as  the  eroding  process  of  the  retained 
products  of  degeneration  goes  on  and  in  addition,  caries  of 
the  malleus  and  incus  in  part  takes  place.  Should,  however, 
the  perforation  withstand  the  pathological  process  and  re- 
maining small,  prevent  proper  drainage,  with  marked  thick- 
ening of  the  folds  of  the  flaccid  membrane,  the  margo  tym- 
panicus  will  largely  bear  the  brunt  of  the  pathological 
changes  and  this  border  of  the  squama  forming  the  upper 
portion  of  the  tympanic  ring  becomes  necrosed  and  reveals 
a  largely  exposed  attic  space.  As  has  been  already  men- 
tioned, the  aditus  and  antrum  bear  a  close  surgical  and 
anatomical  relationship  to  these  attical  suppurations,  being 
located  as  they  are  at  the  posterior  and  superior  angle  of  the 
tympanum  and  forming  the  passage  of  communication  be- 


EXPLANATORY    NOTE    TO    PLATE    III. 


An  original  anatomical  section  showing  the  external  auditory  canal  as  seen  from 
in  front  and  above.  The  tympanic  cavity  with  its  contents  exposed. 

i,  Tegmen  tympani ;  2,  ossicles;  3,  tympanic  membrane;  4,  external  auditory 
canal ;  5,  mastoid  cells ;  6,  aditus  ad  antrum. 

24 


PLATE  III 


Introductory.  25 

tween  it  and  the  mastoid  cellular  system.  It  is  well  to  remem- 
ber at  this  point,  that  slightly  projecting  at  the  entrance  of 
the  antrum  from  the  tympanic  aspect  is  the  osseous  process 
designated  the  spina  tegminis,  which  is  sometimes  apt  to 
interfere  with  the  removal  of  the  incus  by  its  projecting  ledge 
catching  the  hook  used  for  this  purpose. 

While  the  facial  nerve  (see  plate  IV)  assumes  most  active 
importance  in  the  complete  mastoid  operation,  it  also  neces- 
sitates attention  although  subsidiary,  in  conditions  demand- 
ing instrumentation  through  the  external  auditory  canal. 
With  but  a  minimum  of  care  it  may  readily  be  avoided 
in  intratympanic  surgery,  although  occasional  cases  are 
observed  in  which  it  is  extremely  liable  to  be  injured.  In  the 
middle  part  of  its  course  for  a  distance  approximating  about 
fifteen  millimeters,  it  is  separated  from  the  mucous  mem- 
brane of  the  tympanic  cavity  by  a  comparatively  thin  shell 
of  osseous  tissue,  the  Fallopian  canal  crossing  the  posterior 
border  of  the  tympanic  ring  at  the  angle  where  an  imaginary 
horizontal  plane  drawn  through  the  umbo  of  the  membrana 
tympani  extends  to  the  posterior  wall  of  the  osseous  audi- 
tory canal.  Here  the  facial  canal  varies  in  distance  from 
two  to  three  millimeters  from  the  surface  of  the  posterior 
wall  of  the  auditory  canal,  while  the  continuation  of  the 
nerve  outside  of  the  tympanum  still  retains  its  superficial 
position  in  the  posterior  wall  of  the  canal  for  about  five  milli- 
meters further,  being  here  about  three  or  four  millimeters 
from  the  surface,  then  following  its  course  deeply  downward 
and  inward  to  the  depth  of  the  bone  to  reach  its  exit  at  the 
stylomastoid  foramen.  The  most  frequent  source  of  dan- 
ger to  the  facial  nerve  is  the  exposure  in  part  by  dehiscences 
in  the  walls  of  the  Fallopian  canal,  thus  subjecting  it  to  trau- 
matism  in  rare  cases  even  in  competent  hands.  Clefts,  as 
already  mentioned,  may  leave  various  important  and  even 
vital  structures  in  relation  with  the  tympanic  cavity  exposed, 


26  Suppuration  of  the  Middle  Ear. 

and  the  removal  of  an  area  of  granulation  tissue  protecting 
the  dehiscence  may  result  in  serious  damage  from  an  exten- 
sion of  the  inflammation,  or  when  the  jugular  vein  is  thus 
exposed  serious  hemorrhage  may  be  produced.  The  carotid 
artery  may  also  be  exposed  by  such  an  opening  in  the  bone, 
protected  possibly  by  only  a  thin  layer  of  mucous  membrane 
or  fibrous  tissue,  which  often  inefficiently  fills  up  the  gap 
made  by  the  bone  defect,  or  the  roof  of  the  tympanum  or 
antrum  may  be  deficient,  allowing  the  dura  to  become  ex- 
posed, especially  if  the  mucosa  of  this  part  be  destroyed  by 
suppurative  changes. 

The  recognition  of  the  alterations  produced  by  caries  and 
necrosis,  when  the  major  landmarks  have  also  in  part  been 
destroyed,  is  often  a  matter  of  considerable  difficulty,  al- 
though when  the  membrana  vibrans  remains  intact  and  there 
is  found  a  perforation  in  Shrapnell's  membrane  above  the 
short  process  of  the  malleus  with  or  without  the  presence  of 
granulation  tissue,  one  can  be  fairly  accurate  in  regarding 
the  presence  of  dead  bone  as  certain,  with  the  possibility  also 
of  the  malleus  being  destroyed.  At  first  in  order  to  recog- 
nize the  presence  of  caries  or  necrosis,  especial  attention 
should  be  directed  to  the  depths  of  the  external  auditory 
canal  and  careful  search  should  be  made  around  the  entire 
circumference  of  the  membrana  tympani.  With  care,  no 
harm  can  be  done  with  a  delicate  blunt  tipped  probe  cau- 
tiously exploring  the  various  parts  of  the  entire  tympanic 
space,  and  in  cases  of  long  standing,  where  the  mucous  mem- 
brane is  extensively  disorganized,  the  parts  are  not  at  all 
sensitive.  Local  anaesthesia  may  be  necessary  for  thorough 
exploration.  It  is  very  important  to  ascertain  as  accurately 
as  possible  whether  the  purulent  discharge  actually  origi- 
nates from  any  exposed  surface  of  osseous  tissue  or  mucosa, 
or  whether  a  greater  focus  of  necrosis  is  in  a  more  inacces- 
sible part  such  as  the  attic  or  posteriorly  in  the  aditus. 


EXPLANATORY    NOTE    TO    PLATE    IV. 


An  original  anatomical  section  showing  the  relation  of  the  facial  nerve  and  the 
foot  plate  of  the  stapes ;  also  the  Eustachian  tube,  its  isthmus  and  tympanic  opening 
and  its  relation  to  the  tympanic  cavity. 

i  and  2,  Facial  nerve ;  3,  fenestra  ovalis  with  foot  plate  of  stapes ;  4,  fenestra 
rotunda ;  5,  promontory ;  6,  the  floor  of  the  tympanic  cavity,  showing  corrugations ; 
7,  Eustachian  tube ;  8,  isthmus ;  9,  mastoid  cells. 

28 


PLATE  IV 


Introductory.  29 

After  exploring  the  lower  parts  of  the  tympanum,  it  has 
been  recommended  to  carefully  insert  the  probe  under  the 
anterior  and  then  the  posterior  folds  of  the  membrane,  in 
order  to  carry  it  upwards  and  ascertain  the  condition  of  the 
vault.  It  is  often  possible  in  this  manner  to  recognize  the 
presence  of  dead  bone  by  the  peculiar  feeling  imparted  by 
it  to  the  lightly  held  probe. 

Undoubtedly  the  indications  for  treatment  and  especially 
for  surgical  treatment  are  in  a  general  manner  based  upon 
the  pathological  findings.  When  the  affection  is  practically 
limited  to  the  tympanum  proper,  the  pus  secreting  mucous 
membrane  is  congested  and  hypersemic  and  markedly  infil- 
trated with  round  cells,  which  produce  considerable  thicken- 
ing in  various  areas  and  as  the  vessels  are  compressed  by  the 
excessive  cellular  development,  nutritive  changes  take  place 
with  the  formation  of  granulation  tissue,  usually  preceded 
by  a  degeneration  of  the  cellular  constituents  in  part  and  the 
progressive  development  of  fatty  metamorphosis.  At  this 
time  connective  tissue  bands,  forming  irregular  masses  or 
definite  membranous  adhesions,  are  developing  and  in  addi- 
tion to  embedding  the  malleus  and  incus  in  the  granulating 
mass,  the  round  window  may  become  hidden  and  in  occa- 
sional cases  the  entire  tympanic  cavity  may  become  entirely 
filled,  preventing  exploration  until  active  treatment  so  re- 
duces the  mass  that  the  various  surgical  landmarks  can  be 
recognized.  As  these  connective  tissue  bands  are  formed 
by  the  conversion  of  the  round  cells  into  spindle  shaped  cells, 
the  ossicles  are  often  found  bound  together  and  to  the  walls 
of  the  tympanic  cavity  and  attic  by  advanced  serious  tissue 
alterations.  The  mucosa  of  the  tympanic  walls  becomes  still 
more  hypertrophied  or  undergoes  polypoid  degeneration  and 
it  is  not  uncommon  to  find  the  presence  of  cyst-like  spaces 
from  localized  areas  of  degeneration  which  the  membraneous 
folds  have  newly  developed,  or  the  hyperplasia  of  the  normal 


30  Suppuration  of  the  Middle  Ear. 

folds  of  the  mucosa  shut  off  here  and  there  irregular  cavi- 
ties between  their  walls,  which  are  often  entirely  isolated  and 
become  filled  with  pus  or  a  purulent  like  material.  Some  of 
these  spaces  which  are  quite  small  finally  develop  into  defi- 
nite cyst  spaces,  lined  with  cylindrical  or  cubical  epithelial 
cells  and  containing  cholesteatomatous  masses  mixed  with 
mucin.  As  a  result  of  the  serious  involvement  of  the  deeper 
layers  of  the  mucous  membrane  which  acts  as  a  periosteal 
covering  to  the  ossicles  and  walls  of  the  tympanum,  this 
mucoperiosteum  shares  in  the  pathological  changes  and  areas 
of  caries  and  necrosis  of  the  underlying  osseous  walls  takes 
place,  while  at  this  time  the  malleus  and  incus  together  or 
separately  are  beginning  to  become  carious.  Still  later,  in 
addition  to  the  changes  just  enumerated,  an  increased  de- 
struction of  tissue  may  take  place  and  the  flow  of  pus  from 
the  attic  may  be  observed  by  its  discharge  down  the  long 
process  of  the  incus,  while  the  antrum  at  this  time  is  usually 
involved  along  with  greater  or  lesser  changes  in  the  mastoid. 
Well  developed  polypi  often  lie  in  the  tympanic  cavity  or 
project  out  into  the  external  canal  and  cholesteatomatous 
development  is  not  uncommon. 

As  the  head  of  the  malleus  is  suspended  and  in  great  part 
receives  its  blood  supply  from  the  roof  of  the  tympanum,  it 
is  less  prone  to  be  involved  in  the  carious  process  than  the 
neck,  as  this  part  of  the  ossicle  is  liable  to  remain  in  con- 
tinued contact  with  a  purulent  collection  on  account  of  its 
close  relation  with  Prussak's  space.  The  formation  of  the 
mucous  membrane  folds  in  and  around  this  situation  and 
their  relation  to  encapsulated  pus  collections  also  plays  an 
important  role  in  the  pathology  of  attical  suppuration,  de- 
pending to  a  marked  extent  upon  the  individual  variations 
as  to  the  arrangement  of  the  mucous  folds.  Very  probably 
the  degree  of  pathological  change  which  takes  place  is  largely 
influenced  by  the  variety  and  virulence  of  the  predominating 


Introductory.  31 

microorganism  present  in  the  individual  case ;  it  is  not  desired 
here  to  enter  into  the  bacteriology  of  chronic  suppurative 
otitis  media,  other  than  to  merely  indicate  this  relation  and 
the  important  bearing  it  has  upon  the  question  of  preliminary 
treatment  of  the  aural  chamber  and  external  canal  before 
operation,  but  in  the  majority  of  cases  the  streptococcus  pre- 
dominates in  the  discharge  although  the  pneumococcus  is  not 
infrequently  found  and  with  more  general  examination  of 
the  secretion  in  a  larger  number  of  cases,  it  seems  highly 
probable  that  the  tubercle  bacillus  would  be  more  frequently 
found  to  be  present. 


CHAPTER  II. 

PRELIMINARY  PREPARATION  OF  THE 
PATIENT  FOR  OPERATION. 


33 


PRELIMINARY  PREPARATION  OF  THE  PATIENT  FOR 
OPERATION. 

Preliminary  to  any  operation  upon  the  tympanic  cavity 
the  general  health  of  the  patient  should  receive  most  careful 
attention,  as  unless  this  is  done  the  chances  of  a  successful 
result  will  be  much  less  than  those  in  an  individual  otherwise 
healthy.  Attention  to  the  general  health,  as  these  cases  of 
long-continued  aural  suppuration  are  usually  below  the  nor- 
mal, means  increased  tissue  resistance  and  therefore  not  only 
more  rapid  healing  of  the  parts  operated  on,  but  also  more 
perfect  healing,  and  if  strict  attention  be  paid  to  this  factor, 
which  is  often  neglected,  one  will  have  the  satisfaction  of 
seeing  the  curetted  tympanic  mucosa,  for  instance,  assume 
a  healthy  appearance,  instead  of,  as  occurs  in  the  ill-nour- 
ished individual,  the  tissues  further  breaking  down  and  the 
suppuration  continuing  after  the  operation  has  been  cor- 
rectly performed.  Equally  as  important  as  attention  to  the 
general  health  of  the  patient  as  a  preliminary  measure  of 
operation,  is  the  careful  attention  to  the  nasal  chambers  and 
nasopharynx.  It  is  hopeless  to  expect  a  perfect  result  in 
those  cases  where  there  is  ozena  or  a  chronic  nasopharyngitis 

35 


36  Suppuration  of  the  Middle  Ear. 

with  tubal  involvement,  if  these  parts  are  not  placed  under 
as  normal  conditions  as  possible,  for  otherwise  we  may 
remove  the  necrosed  malleus  and  incus  and  carefully  curette 
the  granulation  tissue  from  the  tympanic  cavity,  but  if  the 
ear  is  constantly  being  reinf  ected  by  the  contents  of  a  marked 
pathological  Eustachian  tube,  the  operative  procedures  will 
possibly  diminish  the  discharge,  but  a  permanent  or  even 
temporary  cure  will  be  impossible. 

The  direct  care  of  the  patient  preliminary  to  operation 
consists  in  rendering  as  sterile  as  possible  the  auricle,  external 
auditory  canal  and  the  middle  ear.  The  particular  method 
used  varies  greatly  with  different  operations  and  may  be  from 
slight  cleansing  with  an  antiseptic  solution,  to  the  care  that 
is  exercised  on  a  mastoid  operation;  the  chances  of  success 
being  improved  by  attention  to  scrupulous  cleanliness  of 
instruments,  dressings,  hands  of  the  surgeon,  and  as  far  as 
possible  of  the  parts  to  be  operated  on.  It  may  also  be  well 
to  mention  that  the  usual  rules  of  surgical  asepsis  as  may 
be  modified  to  the  suppurating  cavity  should  be  observed 
whenever  the  probe  is  used  in  the  tympanum  for  diagnostic 
or  other  purposes;  a  useful  and  easy  method  of  doing  this 
when  operative  procedures  are  not  to  be  performed  at  the 
same  time  is  by  rendering  the  canal  and  as  much  of  the  tym- 
panic cavity  as  possible  (providing  there  is  a  large  perfora- 
tion) aseptic,  by  mopping  the  parts  thoroughly  with  cotton 
pledgets  saturated  with  a  1 : 1000  bichloride  solution,  or  if 
this  is  contraindicated  with  a  1 : 50  carbolic  acid  solution. 
When  the  ossicles  are  to  be  removed,  the  external  canal 
should  be  syringed  out  several  times  daily  with  a  solution 
of  bichloride  of  mercury  1 : 3000  or  1 : 5000,  or  with  a  dilute 
solution  of  peroxide  of  hydrogen,  saturated  solution  of  boric 
acid,  or  a  i :  40-60  carbolic  acid  solution.  Just  previous  to, 
or  at  the  time  of  operation,  the  canal  should  again  be  thor- 
oughly cleansed  with  the  stronger  bichloride  of  mercury 


Preparation  of  the  Patient  for  Operation.        37 

solution,  then  the  canal  is  filled  with  peroxide  of  hydrogen 
for  a  minute  or  two  and  again  washed  with  the  bichloride 
solution,  when  it  is  thoroughly  dried  with  sterile  cotton.  In 
doing  this  the  walls  of  the  canal  should  be  thoroughly 
scrubbed  with  a  cotton-tipped  applicator,  and  in  this  manner 
any  pus  or  desquamated  epithelium  which  remains  will  be 
removed.  After  each  cleansing,  a  strip  of  sterilized  or  iodo- 
form  gauze  should  be  introduced  into  the  canal,  reaching 
as  far  as  the  drum  membrane,  and  the  meatus  closed  with  a 
tuft  of  sterile  cotton,  which  should  not  be  removed  until  the 
next  cleansing  unless  it  becomes  stained  with  discharge,  when 
it  should  be  removed  and  replaced  with  a  fresh  piece. 

While,  of  course,  it  is  practically  impossible  in  a  sup- 
purating otitis  to  render  the  canal  or  middle  ear  aseptic,  or 
in  some  cases  even  approximately  so,  yet  we  should  be  most 
careful  to  obtain  as  perfect  a  degree  of  surgical  cleanliness 
as  possible,  both  in  order  to  remove  septic  material  and  to 
prevent  the  added  introduction  of  other  varieties  of  patho- 
genic microorganisms.  It  is  often  surprising  to  observe  the 
degree  of  cleanliness  that  may  be  obtained  in  this  way,  and 
as  has  been  suggested  by  Pritchard  in  this  connection,  that 
while  it  is  not  always  possible  to  thoroughly  sterilize  the 
middle  ear,  yet  if  we  sufficiently  reduce  the  dose  of  the  septic 
poison,  the  natural  sterilizing  power  of  the  tissues  will  be 
enabled  to  cope  successfully  with  the  enemy.  In  removing 
polypi  or  large  granulations  from  the  canal  or  tympanic  cav- 
ity without  further  operative  procedures,  a  solution  of  1 : 3000 
bichloride  of  mercury  in  alcohol  makes  a  most  efficient  anti- 
septic. While  the  head  is  inclined,  with  the  ear  to  be  operated 
on  uppermost,  a  few  drops  of  this  solution  are  placed  in  the 
canal,  being  allowed  to  remain  for  some  minutes,  then  re- 
moved with  sterile  cotton  and  this  process  repeated  a  number 
of  times,  as  often  as  may  seem  necessary  in  the  particular 
case.  While  this  acts  as  an  active  antiseptic  agent,  it  does 


38  Suppuration  of  the  Middle  Ear. 

not  irritate  nor  coagulate  the  albumenous  discharges  and  at 
the  same  time,  by  its  dehydrating  property,  to  some  extent, 
it  renders  the  vascular  tissues  to  be  removed  lighter  in  color 
and  reduced  in  size. 

When  ossiculectomy  is  to  be  performed  in  a  hospital  ser- 
vice it  is  not  necessary  to  specify  here  any  particular  method 
of  sterilizing  the  instruments  used,  but  where  such  facilities 
are  not  possible,  one  can  be  certain  of  the  asepsis  of  his 
instruments  by  boiling  the  larger  ones  in  a  I  or  2  per  cent, 
bicarbonate  of  soda  solution  for  five  minutes,  while  the  more 
delicate  instruments  and  knives  are  placed  in  the  solution  for 
not  over  a  minute  and  then  immersed  in  alcohol.  The  ques- 
tion of  anaesthesia  in  intratympanic  operations  depends  en- 
tirely upon  the  amount  of  tissue  to  be  removed  and  the  forti- 
tude of  the  patient.  When  it  is  desired  to  remove  a  freely 
exposed  malleus  or  its  remnants,  or  to  snare  a  polypus  or  a 
group  of  exuberant  granulation  tissue,  local  anaesthesia  is 
all  that  is  necessary  and  in  a  very  small  number  of  individ- 
uals where  the  affected  tissues  are  not  unduly  sensitive  or 
the  fortitude  of  the  individual  is  unduly  great,  even  more 
extensive  operative  procedures  may  be  accomplished  under 
such  circumstances.  Local  anaesthesia  is  also  amply  suffi- 
cient when  a  small  perforation  in  the  membrana  tympani 
requires  enlarging,  or  when  there  are  a  limited  number  of 
easily  accessible  adhesive  bands  to  be  destroyed.  While 
there  is  a  great  diversity  of  opinion  in  regard  to  the  use  of 
local  or  general  anaesthesia  for  tympanic  operations,  one 
may  in  general  state  that  for  the  minor  procedures  as  pre- 
viously mentioned,  local  anaesthesia  is  amply  sufficient,  while 
for  ossiculectomy,  with  or  without  curettage  of  the  tympanic 
walls,  general  anaesthesia  is  absolutely  necessary.  For  local 
anaesthetic  purposes,  cocaine  in  from  10  to  25  per  cent,  solu- 
tion is  almost  universally  used;  a  few  drops  are  placed  in 
the  ear  for  fifteen  or  twenty  minutes  and  the  parts  are  dried 


Preparation  of  the  Patient  for  Operation.        39 

after  the  tissues  have  become  insensitive  and  as  the  opera- 
tion proceeds  and  more  inaccessible  parts  are  reached,  areas 
to  be  further  cocainized  are  touched  with  a  cotton  tuft  satu- 
rated with  the  solution.  The  objection  to  this  anaesthetic 
here  is  that  often  a  considerable  amount  is  necessitated  and 
untoward  symptoms  may  occur  if  the  granulation  tissue 
removed  exposes  fresh  areas  by  which  the  drug  can  be 
rapidly  absorbed.  Eucain  may,  however,  be  substituted  in 
such  cases  with  considerable  satisfaction,  or  in  cases  where 
it  is  desired  to  expose  the  attic  in  part,  Schleich's  solution 
has  been  used  somewhat,  injected  into  the  superior  wall  of 
the  external  canal  in  the  immediate  vicinity  of  the  area  to 
be  operated  on.  While,  when  the  surface  to  be  operated  on 
is  limited  in  extent,  and  especially  when  perforations  in  the 
drum  require  enlargement  for  drainage,  Gray's  formula  of 
10  per  cent,  cocaine  in  equal  parts  of  anilin  oil  and  alcohol, 
has  been  efficient  in  my  hands  in  producing  a  marked  degree 
of  anaesthesia  in  a  considerable  number  of  cases. 

When  the  patient  is  nervous  or  shows  signs  of  consider- 
able restlessness,  a  general  anaesthetic  must  be  employed, 
the  choice  depending  almost  entirely  upon  the  surgeon. 
Beco  records  a  case  in  which  he  removed  the  malleus  under 
ethyl  bromide  anaesthesia,  but  as  a  general  rule  ether  or 
chloroform  are  to  be  preferred.  As  indicated  above,  gen- 
eral anaesthesia  is  always  essential  when  the  intratympanic 
operation  is  to  be  of  any  extent,  when  carious  bone  is  to  be 
removed  or  when  curetting  is  practised,  as  the  movements 
of  the  patient  interfere  with  the  work  of  the  operator. 


CHAPTER  III. 

THE  TREATMENT  OF  THE  MUCOSA  AND 
MUCO-PERIOSTEUM  OF  THE  ? 
TYMPANIC  CAVITY. 


THE   TREATMENT   OF   THE   MUCOSA    AND    MUCO-PERIOS- 
TEUM   OF   THE   TYMPANIC   CAVITY. 

In  a  previous  chapter  the  various  pathological  changes 
taking  place  in  the  tympanic  cavity  during  the  course  of  a 
chronic  suppurative  otitis  media,  were  pointed  out  in  their 
relation  to  various  changes  in  the  surgical  landmarks  as  de- 
termining the  character  of  the  surgical  treatment,  especially 
as  indicated  by  the  minute  diagnostic  features  present  in  a 
given  case.  It  is  here  desired  to  still  more  forcibly  empha- 
size the  complete  interdependence  between  the  pathology  of 
this  affection  and  the  essential  features  concerned  in  its  sur- 
gical treatment.  As  regards  operative  procedures  through 
the  external  canal,  the  conditions  necessitating  such  will  be 
taken  up  under  the  subdivisions  of  operations  upon  the  mem- 
brana  tympani  and  operations  upon  the  mucosa  and  muco- 
periosteal  lining  of  the  tympanic  cavity,  the  latter  dealing 
with  hyperplasia,  granulation  tissue,  polypi,  and  finally  cho- 
lesteatomatous  masses  susceptible  of  relief  by  intratympanic 
operations,  in  contradistinction  to  more  extensive  forma- 
tions, which  necessitate  a  radical  mastoid  operation  for  their 
successful  amelioration. 

43 


44  Suppuration  of  the  Middle  Ear. 

While  the  membrana  tympani  is  affected,  both  as  regards 
its  continuity  and  structure  in  all  cases  of  chronic  suppura- 
tion, it  is  especially  desired  to  call  attention  here  to  the  sur- 
gical treatment  of  perforations  and  adhesions  of  this  mem- 
brane as  they  influence  the  course  of  the  disease.  When  the 
perforation  is  very  small,  so  that  the  escape  of  purulent  or 
mucopurulent  masses  through  it  is  rendered  impossible,  or 
where  the  symptoms  present  indicate  a  partial  retention  of 
pus  from  this  cause,  it  should  be  enlarged  with  a  small 
straight  or  curved  knife  as  the  operator  may  prefer.  The 
canal  should  be  rendered  as  sterile  as  possible  by  the  methods 
previously  indicated  and  with  a  10  to  20  per  cent,  solution 
of  cocaine  or  the  cocaine-anilin  oil  formula,  the  perforation 
and  adjacent  parts  of  the  membrana  tympani  are  moistened 
with  the  anaesthetic  for  some  minutes.  Good  illumination 
and  preferably  the  electric  photophore  is  essential,  and  with 
the  patient  in  the  erect  posture,  the  knife  is  introduced 
through  the  perforation  and  it  is  enlarged  by  an  incision, 
usually  downwards  towards  the  floor  of  the  tympanum,  in 
order  to  obtain  the  best  drainage,  or  in  some  cases  it  may  be 
advisable  to  enlarge  the  perforation  by  an  incision  from  2 
to  5  millimeters  long  in  the  direction  of  any  localized  bulging 
of  the  drum  head  that  may  be  present.  In  some  instances, 
where  the  mucosa  alone  is  affected  and  necrosis  of  the  ossi- 
cles or  tympanic  walls  is  not  present,  this  slight  operation 
will  effectually  relieve  the  retention  and  may  be  all  the  oper- 
ative procedure  necessary  to  obtain  a  complete  cure,  although 
such  a  result  is  but  rarely  obtained.  As  a  result  of  the 
enlargement  of  the  perforation  there  is  a  free  discharge  of 
the  confined  purulent  secretion,  the  tympanic  cavity  is  more 
thoroughly  exposed  and  when  the  secretion  is  tenacious  and 
clings  to  the  mucosa,  it  can  thus  be  more  readily  removed 
and  later  medical  treatment  of  the  otorrhcea  is  thus  greatly 
facilitated. 


Treatment  of  the  Mucosa.  45 

As  this  represents  the  most  simple  operation  performed 
for  the  relief  of  chronic  suppuration,  it  often  fails  to  be  of 
any  benefit  on  account  of  the  tympanum  being  more  exten- 
sively affected  than  may  be  expected,  or  as  frequently  hap- 
pens, the  favorable  results  are  only  transient  as  the  incision 
into  the  drum  often  rapidly  closes  and  the  benefits  thus 
obtained  are  lost.  The  perforation  should  be  enlarged  in 
the  same  manner,  when  it  is  very  small  or  pouting,  and  there 
are  minor  evidences  of  retention  with  redness  of  the  drum 
and  beginning  inflammatory  phenomena.  In  addition  to  the 
small  size  of  the  perforation  per  se,  it  may  become  still  more 
minute  by  a  thickening  of  its  circumference  from  hyper- 
plastic  changes  in  the  membrana  tympani  and  proliferation 
of  the  epithelium  around  its  borders,  thus  preventing  the 
proper  egress  of  the  contained  secretion.  The  perforation 
should  also  be  enlarged  as  an  initial  measure,  when  there  are 
evidences  of  cholesteatomatous  masses  present  acting  as  a 
plug  and  obstructing  the  previously  existing  perforation,  or 
when  granulation  tissue  in  the  tympanic  cavity  acts  as  a 
source  of  obstruction,  especially  when  there  also  exists  some 
fullness  of  the  drum;  and  finally  the  perforation  should  be 
amply  enlarged  in  all  cases  where  other  operative  measures 
do  not  appear  to  be  indicated,  but  in  which  there  is  not  the 
necessary  space  present  to  cleanse  the  middle  ear  or  to  intro- 
duce the  applicator  or  syringe  to  remove  retained  products 
of  degeneration.  When  it  is  found  necessary  to  make  a 
second  perforation  in  the  membrana  tympani,  the  operation 
does  not  differ  in  any  essentials  from  that  of  enlarging  the 
size  of  a  previous  perforation,  but  as  the  initial  incision  into 
the  drum  head  is  somewhat  painful,  although  the  sensibilities 
of  the  tympanic  membrane  are  obtunded  after  a  long  period 
of  suppuration,  it  is  well  to  thoroughly  anaesthetize  the  area 
to  be  opened  as  well  as  possible  with  a  20  per  cent,  warm 
cocaine  solution  and  with  the  head  of  the  patient  firmly  held 


46  Suppuration  of  the  Middle  Ear. 

in  position,  an  incision  4  or  5  millimeters  long  is  made  in  the 
drum,  preferably  as  low  as  possible,  or  wherever  bulging, 
if  such  be  present,  is  most  prominent.  In  other  words,  this 
operation  should  be  performed  practically  the  same  as  an 
ordinary  myringotomy  in  acute  otitis.  As  suggested  by 
Politzer,  the  indications  for  a  second  perforation  under  such 
conditions  are  in  certain  cases  where  there  are  adhesions 
between  the  membrana  tympani  and  inner  tympanic  wall  (see 
plate  V),  where  there  are  isolated  loculi  containing  purulent 
material  and  also  in  those  cases  where  there  is  considerable 
bulging  of  the  membrana  tympani  at  some  distance  from  the 
original  perforation,  and  where  there  are  more  or  less  fre- 
quent recurring  attacks  of  pain,  indicative  of  a  focal  area 
of  retention  in  the  deeper  parts  of  the  tympanic  cavity.  As 
still  further  indications  for  the  adoption  of  this  measure  may 
be  suggested  those  cases  in  which  at  a  distance  from  the 
original  perforation,  masses  of  cholesteatomatous  material 
or  polypi  or  granulations  produce  an  isolated  bulging  of  the 
membrane,  or  in  perforation  of  Shrapnelf s  membrane  if 
slight  symptoms  of  pus  retention  are  present  in  the  lower 
tympanic  space. 

For  the  removal  of  adhesions  between  the  membrana 
tympani  and  the  tympanic  wall,  various  small  tympanic 
knives  are  necessary,  especially  those  with  the  blade  curved 
at  right  angles  to  the  shaft.  If  the  perforation  in  the  drum 
is  not  sufficiently  ample  for  the  necessary  manipulations,  it 
may  be  enlarged  as  previously  mentioned,  or  the  greater  part 
may  require  removal;  but  this  is  rarely  the  case,  as  in  such 
instances  the  drum  head  is  already  in  great  part  destroyed. 
The  most  frequent  form  of  adhesion  of  this  character,  and 
practically  the  only  one  which  requires  consideration  in  this 
connection,  is  when  the  tympanic  membrane  becomes  at- 
tached to  the  inner  tympanic  wall  and  where  the  posterior 
margin  of  the  large  perforation  is  firmly  adherent  to  the 


EXPLANATORY    NOTE    TO    PLATE   V. 


A  schematic  side  view  of  the  tympanic  cavity  showing  a  retracted  cicatrix  and 
intra-tympanic  relations. 

i,  External  auditory  canal;  2,  retracted  cicatrix;  3,  line  of  drum  membrane;  4, 
suspensory  ligament;  5,  attic;  6,  incus;  7,  malleus;  8,  stapes;  9,  promontory;  10, 
hypo-tympanic  space. 

48 


PLATE  V 


EXPLANATORY   NOTE   TO    PLATE   VI. 


A  schematic  side  view  of  the  tympanic  cavity  showing  an  adhesive  process 
between  the  drum  membrane  and  promontory. 

i,  External  auditory  canal;  2,  retracted  drum  membrane;  3,  adhesions  between 
the  drum  membrane  and  promontory;  4,  promontory. 

50 


PLATE  VI 


EXPLANATORY    NOTE    TO    PLATE   VII. 


A  schematic  side  view  of  the  tympanum  illustrating  the  cutting  of  adhesions 
between  the  promontory  and  drum  membrane. 

i,  Knife  in  position;  2,  adhesion  partly  severed. 

52 


PLATE  VII 


Treatment  of  the  Mucosa.  53 

promontory,  while  the  anterior  border  remains  entirely  free 
(see  plate  VI).  When  such  a  condition  is  found,  there  is 
sure  to  be  retention  of  pus  or  epithelial  debris  in  the  pocket 
thus  formed,  with  all  the  symptoms  of  retention.  With  an 
angular  knife,  it  may  be  possible  to  dissect  away  the  attached 
drum  from  the  inner  tympanic  wall  (see  plate  VII),  or  in 
case  this  is  not  feasible,  the  straight  knife  should  be  used  and 
the  membrana  tympani  removed  at  its  circumference,  the  cir- 
cular incision  being  made  a  line  or  so  from  the  annulus,  and 
it  is  usually  necessary  in  these  cases  to  also  remove  the  mal- 
leus, the  technique  of  which  will  be  described  in  a  later  chapter. 
Inasmuch  as  the  mucous  membrane  of  the  tympanic  cav- 
ity is  in  such  intimate  connection  with  its  contained  ossicles 
and  bony  walls  and  as  they  depend  for  nutrition  upon  it,  a 
careful  study  of  the  morbid  changes  of  the  mucosa  is  essen- 
tial to  a  satisfactory  understanding  of  the  rationale  of  some 
of  the  necessary  operative  procedures.  In  general,  the  muco- 
periosteal  lining  of  the  tympanic  cavity,  including  the  attic 
and  antrum,  may  present  the  various  stages  of  thickening, 
the  development  of  a  granular  stage  or  ulceration,  or  as  more 
frequently  happens  all  of  these  changes  are  found  associated 
in  the  majority  of  cases  upon  which  operation  is  indicated. 
In  color,  it  may  vary  from  the  deep  red  of  chronic  conges- 
tion to  a  yellow-gray  hue  from  degenerative  changes.  It  is 
always  markedly  thickened,  and  while  rarely  smooth  in  ap- 
pearance, it  is  more  often  irregular  or  elevated  into  well- 
formed  granulation  masses  which  may  be  so  excessive  in 
development  that  the  entire  tympanic  cavity  becomes  filled. 
When  such  is  the  case,  one  will  usually  on  careful  examina- 
tion find  some  evidences  of  involvement  of  the  antrum  and 
pneumatic  cells  of  the  mastoid  process,  thus  precluding  oper- 
ation through  the  canal  and  strongly  indicating  the  opening 
of  the  antrum  by  way  of  the  mastoid  process.  The  histo- 
logical  changes  which  have  a  direct  bearing  on  the  develop- 


54  Suppuration  of  the  Middle  Ear. 

ment  of  granulation  tissue  and  are  intimately  concerned  in 
the  production  of  necrosis  and  caries,  consists  principally  of 
the  previously  described  round  cell  infiltration  and  in  addi- 
tion the  formation  of  new  vascular  channels.  At  first  the 
periosteal  layer  of  the  mucosa  does  not  suffer  much  morbid 
change,  but  the  subepithelial  layer  is  densely  infiltrated  and 
later  becomes  practically  replaced  by  a  dense  mass  of  granu- 
lation tissue  in  which  the  blood  vessels  become  markedly 
dilated,  tortuous  and  increased  in  number,  rendering  the 
parts  extremely  vascular,  and  thus  greatly  increasing  the 
difficulties  of  curetting.  Later  fatty  degeneration  takes 
place  in  certain  portions,  while  in  other  parts  of  the  tympanic 
cavity  adhesions  are  formed  from  the  development  of  bands 
of  newly  grown  fibrous  tissue,  which  may  appear  as  a  more 
or  less  elevated,  diffuse  thickening  of  the  mucosa,  or  as 
cicatricial  tissue  markedly  interfering  with  the  removal  of 
the  ossicles.  Following  this,  or  more  frequently  accom- 
panying it,  are  found  ulcerative  changes  in  the  mucosa,  the 
breaking  down  of  the  tissue  in  isolated  spots  with  the  cutting 
off  of  nutrition  to  the  underlying  bone  and  the  development 
of  caries. 

At  the  same  time  as  the  mucosa  covering  the  osseous 
walls  of  the  tympanum  is  undergoing  these  changes,  serious 
damage  is  also  going  on  in  the  tympanic  membrane,  and  as 
a  rule,  that  portion  lying  between  the  manubrium  and  the 
periphery  is  most  seriously  involved.  While  other  portions 
may  be  destroyed,  the  attachment  to  the  annulus  tympanicus 
remains  more  or  less  intact,  although  a  crescentic  portion 
alone  in  this  situation  may  be  all  that  remains  of  the  mem- 
brane. In  long-standing  cases  where  the  destruction  is  very 
great,  the  membrane  is  quite  thickened  either  by  a  hyper- 
plasia  of  the  dermoid  layer  or  as  a  result  of  a  similar  change 
taking  place  in  the  mucous  membrane  forming  its  internal 
surface  and  when  this  occurs,  it  is  apt  to  temporarily  em- 


Treatment  of  the  Mucosa.  55 

barrass  the  operator  by  the  profuse  bleeding  which  takes 
place  from  its  cut  surface  in  removing  it,  to  gain  better  access 
to  the  contents  of  the  tympanum. 

In  considering  the  indications  for  ossiculectomy,  when 
the  nature  of  the  purulent  discharge  in  the  absence  of  other 
marked  indications  assumes  some  importance,  one  should 
always  bear  in  mind  that  when  the  mucosa  becomes  con- 
siderably altered  in  structure  and  its  glandular  elements  are 
in  great  part  destroyed,  the  secretion  becomes  markedly 
altered  in  its  nature  and  is  apt  to  be  thin,  irritating  and  pos- 
sibly have  an  offensive  odor.  While  this  is  more  or  less  indi- 
cative of  necrotic  bone,  yet  such  is  not  always  the  case,  and 
if  the  hearing  remains  in  fair  condition,  ossiculectomy  or 
curettage  may  be  not  at  all  advisable,  when  such  would  be 
necessary  if  dead  bone  were  present.  In  contradistinction 
to  this  condition,  the  mucosa  over  the  inner  tympanic  wall 
may  present  such  a  degree  of  hypertrophy  that  it  is  projected 
forward  and  ofter  markedly  resembles  the  congested  tym- 
panic membrane,  if  such  be  absent;  the  proper  condition, 
however,  being  recognized  by  the  probe  and  the  loss  of  con- 
tinuity of  the  canal  wall  in  the  absence  of  the  drum. 

Two  methods  of  treatment  are  available  for  the  granular 
changes  in  the  tympanic  mucosa:  the  curette  and  cauteriza- 
tion. After  cleansing  both  canal  and  middle  ear,  the  mucous 
membrane  is  cocainized  and  if  cauterization  is  desired  the 
parts  are  thoroughly  dried.  The  galvanocautery  produces 
too  much  reaction  in  this  location  and  had  better  not  be  used, 
but  very  favorable  results  may  be  obtained  by  the  careful 
application  of  chromic  acid  to  limited  areas.  The  acid  is 
fused  on  a  delicate  probe  or  applicator,  and  the  parts  of  the 
mucosa  desired  are  lightly  touched,  so  that  several  points 
are  made  over  the  tissue  and  when  the  applications  are  con- 
sidered sufficient,  the  excess  of  acid  is  removed  by  lightly 
moistening  the  parts  with  a  cotton-tipped  applicator  contain- 


56  Suppuration  of  the  Middle  Ear. 

ing  an  antiseptic  alkaline  solution.  While  this  treatment 
will  be  sufficient  in  those  cases  where  the  changes  in  the 
mucosa  have  not  developed  into  large  granulations,  or  too 
much  tissue  alteration  has  not  taken  place,  yet  curettage 
is  usually  indicated.  With  a  sharp  spoon  or  curette  the 
tissue  is  gently  removed,  especial  care  being  taken  in  avoid- 
ing undue  force  when  the  promontory  wall  is  curetted,  on 
account  of  the  danger  of  injuring  the  important  structures 
within.  Unless  dead  bone  is  present,  care  should  always  be 
exercised  to  avoid  wounding  the  periosteal  layer  of  the  mu- 
cosa, and  this  can  readily  be  avoided  by  lightly  curetting. 
In  treating  the  tympanum  in  this  way,  one  should  always 
use  a  spoon  with  a  stem  that  is  flexible  enough  to  be  bent  to 
any  angle  desired  and  yet  will  be  sufficiently  strong  to  remove 
the  tissue,  it  being  necessary  to  often  bend  the  curette  to 
reach  otherwise  inaccessible  parts  and  at  the  same  time  not 
disturb  the  ossicular  chain.  After  curettage,  or  even  in 
some  cases  when  they  first  come  under  observation,  the  vas- 
cular supply  has  diminished  and  sclerotic  changes  take  place 
with  the  production  of  a  dermoid  appearance  of  the  mucosa, 
especially  of  the  inner  tympanic  wall;  this  is  due  to  the 
redevelopment  of  the  epithelial  layer  either  from  areas  which 
have  not  been  seriously  compromised  by  the  suppuration  or 
from  extension  inwards  of  the  epithelium  from  the  canal. 
When  the  surface  so  transformed  is  smooth,  it  indicates  the 
cessation  of  suppuration  at  that  point  and  should  be  care- 
fully avoided  when  using  the  curette,  but  when  the  epithe- 
lium undergoes  excessive  proliferation  and  becomes  heaped 
up  in  layers,  indicating  a  tendency  to  the  so-called  cholestea- 
toma  formation,  it  requires  curettage,  which  will  be  described 
under  its  appropriate  heading. 

Considerable  diversity  of  opinion  exists  in  regard  to 
curetting  the  tympanic  cavity,  and  while  the  author  is  of 
the  opinion  as  advised  here  in  the  treatment  of  the  affected 


Treatment  of  the  Mucosa.  57 

mucosa,  that  with  care  no  untoward  results  are  produced, 
yet  some  objections  have  been  raised  against  the  perform- 
ance of  this  operation,  especially  after  ossiculectomy,  as  it 
is  claimed  that  the  facial  nerve  may  be  wounded  and  damage 
done  to  other  parts.  One  can  hardly  see  how  it  is  possible 
by  nonsurgical  treatment  to  restore  an  enormously  thickened 
and  pus-secreting  membrane  to  anything  approaching  the 
normal  without  cauterization  or  curettage,  as  in  cases  which 
are  observed,  it  will  be  found  that  without  such  measures 
the  progressive  stages  of  tissue  destruction  as  previously 
outlined  will  ensue  in  many  cases,  and  instead  of  marked 
benefit  being  obtained  by  curettage,  ulceration  and  necrosis 
will  ensue,  necessitating  the  removal  of  the  ossicles  and 
necrosed  bone  from  the  tympanic  walls.  In  regard  to  curet- 
ting being  omitted  after  ossiculectomy  as  an  essential  part 
of  the  operation  on  account  of  the  spontaneous  disappearance 
of  the  excessive  thickening  of  the  mucosa  and  the  recovering 
of  denuded  bone  with  new  membrane,  the  writer  is  of  the 
opinion  that  such  views  are  erroneous,  and  that  such  a  resto- 
ration to  normal  does  not  take  place,  but  that  this  favorable 
result  can  be  obtained  in  practically  all  cases  where  such  an 
operation  is  indicated,  only  by  the  careful  and  thorough 
cleansing  of  the  tympanic  walls  by  the  curette.  That  cau- 
terization of  the  mucosa  in  this  locality  is  not  entirely  free 
from  danger  is  suggested  by  the  cases  reported  by  Alderton, 
in  one  of  which  the  application  of  chromic  acid  to  the  mucosa 
in  the  vicinity  of  the  Fallopian  canal  produced  a  severe 
attack  of  facial  herpes,  while  in  another  case  the  same  pro- 
cedure produced  an  intense  local  inflammation  of  the  facial 
nerve  which  was  lying  exposed  beneath  the  cauterized  soft 
tissue  and  the  facial  palsy  ensuing  was  only  relieved  by  a 
radical  operation.  Of  course  these  are  exceptional  instances 
of  untoward  results  from  this  procedure,  but  that  in  careful 
hands  such  can  occur,  emphasizes  the  necessity  of  extreme 


58  Suppuration  of  the  Middle  Ear. 

caution.  When  evidence  warrants  the  belief  that  the  facial 
nerve  is  in  any  way  exposed  in  the  tympanum,  one  should 
always  avoid  its  vicinity  in  using  the  sharp  spoon,  but  when 
the  mucosa  demands  removal  in  such  situations,  this  instru- 
ment may  be  replaced  by  the  dull  wire  curette,  which  will  be 
found  of  much  service  for  this  purpose. 

Flat,  sessile  granulations  should  be  curetted  away  and 
where  the  probe  has  revealed  the  presence  of  dead  bone 
beneath,  it  should  also  be  removed  in  the  manner  to  be  later 
described,  as  in  that  form  of  granulation  tissue  springing, 
not  from  the  mucosa,  as  has  just  been  described,  but  from 
an  area  of  caries,  it  is  impossible  to  expect  any  permanent 
results  from  the  operation  until  the  entire  diseased  area  has 
been  removed ;  otherwise  within  a  very  short  time  the  granu- 
lation tissue  will  again  return.  When  the  discharge  is  very 
abundant,  associated  with  excessive  granulation  develop- 
ment, so  that  the  fundus  of  the  external  canal  appears  filled 
with  the  growth  and  there  is  also  present  a  foul  odor,  one 
is  very  apt  to  find  a  larger  area  than  the  tympanum  involved, 
and  operation  through  the  canal  will  be  of  no  benefit,  even 
if  it  should  drain  the  antrum,  as  the  mastoid  cells  are  also 
probably  affected.  When  a  mass  of  granulations,  associated 
with  a  purulent  discharge  of  an  irritating  character,  are 
found  at  the  posterior  end  of  the  tympanum,  it  is  usually 
indicative  that  the  source  of  the  discharge  is  in  the  antrum. 
The  presence  of  a  similar  mass  apparently  originating  from 
a  point  directly  above  the  membrana  tympani,  is  strongly 
suggestive  that  the  pathological  changes  producing  the  puru- 
lent discharge  are  located  in  the  vault  of  the  tympanum,  and 
if  recurrence  occurs  after  their  removal,  ossiculectomy  will 
be  necessary  to  obtain  a  satisfactory  result.  While  as  a  rule 
the  mass  of  granulation  tissue  found  in  the  middle  ear  springs 
from  its  interior,  yet  in  every  case,  the  possibilities  of  this 
vascular  tissue  originating  from  without  this  chamber  should 


EXPLANATORY    NOTE    TO    PLATE   VIII. 


No.  i.  Normal  drum  membrane. 

No.  2.  Retracted  drum  membrane,  with  thinning  of  the  drum  membrane  showing  the 

stapedo-incudal  articulation  and  the  shadow  of  the  Eustachian  tube. 
No.  3.  Capillary  engorgement  of  the  drum  membrane  and  handle  of  the  malleus. 
No.  4.  Effusion  behind  the  drum  membrane  before  inflation. 
No.  5.  Effusion  behind  the  drum  membrane  after  inflation. 
No.  6.  An  oval-shaped  perforation  in  the  inferior  portion  of  the  drum  membrane. 


60 


PLATE  VIII 


Treatment  of  the  Mucosa.  61 

always  be  ascertained  previous  to  their  removal  from  the 
vault,  as  when  the  bone  of  the  tegmen  becomes  eroded,  the 
dura  mater  over  this  area  rapidly  becomes  covered  with 
granulation  tissue  and  unless  this  is  ascertained  by  the  care- 
ful use  of  the  probe,  serious  untoward  results  are  liable  to 
ensue  upon  their  removal.  This  factor  in  its  uncertainty, 
should  alone  emphasize  the  necessity  for  careful  asepsis  even 
in  the  use  of  the  probe  in  this  region,  and  if  the  condition 
mentioned  should  be  found  to  exist,  great  care  should  be 
taken  to  avoid  infecting  the  cranial  contents  during  even  the 
most  trivial  operative  procedures  in  this  locality. 

In  their  surgical  aspect,  both  polypi  and  granulations  are 
the  result  of  irritation  from  the  purulent  discharge,  but  they 
also  assume  an  active  part  in  keeping  up  the  inflammation 
and  act  as  barriers  to  the  free  exit  of  pus.  On  this  account 
their  early  removal  is  essential,  both  to  obtain  necessary 
drainage  and  to  further  diminish  the  inflammatory  changes 
in  the  tissues.  This  is  frequently  observed  in  cases  where 
there  has  been  extensive  destruction  of  the  membrana 
vibrans  with  the  attical  space  crowded  with  granulations, 
forming  an  irregular  mammillated  cushion  over  the  internal 
tympanic  wall.  Under  such  circumstances  the  upper  edge 
of  the  osseous  wall  above  the  membrana  is  softened  and  in 
part  destroyed  and  with  the  membrana  tympani  should  be 
removed.  With  the  snare  the  granulations  projecting  for- 
ward can  be  readily  removed,  while  those  on  the  posterior 
wall  and  the  base  of  those  snared  away  should  be  lightly 
curetted  with  the  sharp  spoon,  when  the  probe  may  then  be 
used  to  ascertain  the  presence  of  areas  of  carious  bone,  which 
should  be  curetted  away  in  the  manner  to  be  later  described. 
Often  in  these  cases  where  Shrapnell's  membrane  has  been 
so  extensively  destroyed,  the  incus  alone,  or  the  malleus  as 
well,  shows  necrotic  changes  and  in  long-standing  cases  only 
a  remnant  of  the  ossicles  will  be  found,  when  a  complete 


62  Suppuration  of  the  Middle  Ear. 

ossiculectomy  should  be  performed,  or  if  examination  shows 
that  the  carious  process  has  extended  backwards  and  up- 
wards into  the  aditus  and  antrum,  it  is  futile  to  expect  a 
favorable  result  unless  the  antrum  be  opened  by  the  mastoid 
route.  When  an  apparent  mass  of  granulation  tissue  has 
been  removed  with  snare  or  curette,  one  should  examine  the 
specimen  to  ascertain  if  particles  of  necrosed  bone  have  been 
brought  away  with  it  and  to  differentiate  it  from  those  rare 
cases  of  granuloma  in  which  gritty  particles  are  also  found, 
but  which  do  not  indicate  the  presence  of  carious  osseous 
tissue.  An  exceedingly  instructive  case  of  this  nature  is 
reported  by  Pierce  of  a  granuloma  of  Prussak's  space  simu- 
lating caries,  which  occurred  over  the  short  process  of  the 
malleus  and  partially  obscured  this  portion  of  the  flaccid 
membrane  from  view.  The  apparent  granulation  tissue 
mass  was  about  the  size  of  a  pea  protruding  through  the 
flaccid  membrane  and  the  probe  showed  that  it  was  attached 
by  a  small  pedicle  and  in  many  respects  resembled  very 
closely  the  appearance  so  characteristic  of  necrosis  of  the 
incus.  The  growth  was  removed  and  the  cavity  cleaned 
out  with  the  curette  through  the  opening,  and  a  number  of 
gritty  particles  were  found  resembling  necrotic  bone,  but  the 
microscope  and  chemical  tests  revealed  that  the  particles  were 
organic  and  not  dead  bone.  As  the  presence  of  necrosis 
was  thus  eliminated,  the  cavity  was  packed  with  gauze  and 
complete  recovery  ensued. 

In  addition  to  the  snare,  curette,  either  sharp  or  dull,  or 
cautery  for  the  removal  of  well-developed  granulation  tissue, 
one  may  use  for  their  removal  even  with  greater  satisfac- 
tion, some  form  of  the  various  cutting  forceps,  Hartmann's 
especially  being  very  useful  for  this  purpose.  Before  intro- 
ducing the  forceps  that  may  seem  most  acceptable  to  the 
operator,  the  location  of  the  tissue  to  be  removed  and  its 
relation  to  dangerous  areas  should  be  accurately  determined 


EXPLANATORY    NOTE    TO    PLATE    IX. 


No.  x.  Multiple  perforation  of  the  drum  membrane  in  a  case  of  tubercular  affection 
of  the  middle  ear. 

No.  2.  Large  kidney-shaped  perforation,  exposing  the  stapedo-incudal  articulation. 
The  tip  of  the  handle  of  the  malleus  is  also  free  and  the  Eustachian  open- 
ing is  visible. 

No.  3.  Multiple  healed  perforations  showing  transparent  cicatrices. 

No.  4.  Large  cicatrized  perforation  in  the  postero-superior  quadrant  of  the  drum 
membrane. 


64 


PLATE  IX 


Treatment  of  the  Mucosa.  65 

and  under  good  illumination  so  that  the  parts  operated  upon 
can  be  easily  seen  during  the  entire  procedure,  the  forceps 
are  passed  through  the  perforation  in  the  drum  if  it  will 
admit  them  and  if  not  it  should  be  amply  enlarged  and  the 
tissue  desired  is  bitten  off,  until  all  of  it  has  been  thoroughly 
removed.  This  may  be  followed  up  by  gently  smoothing  the 
more  or  less  ragged  surface  which  is  always  left,  with  the 
sharp  curette  or  should  the  base  of  a  well-defined  granula- 
tion which  has  developed  polypi  formation  be  present,  it  is 
best,  after  controlling  the  bleeding  and  thoroughly  drying 
the  parts,  to  touch  it  lightly  with  chromic  acid  or  a  strong 
solution  of  nitrate  of  silver.  In  cauterizing  the  tissues  of 
the  tympanic  cavity  with  any  of  the  more  active  cauterants, 
care  should  always  be  exercised  to  destroy  only  the  exact 
tissue  desired  and  avoiding  the  contact  of  the  probe  contain- 
ing the  cauterant  or  the  galvano-cautery  if  this  should  be 
used,  with  other  parts,  both  to  avoid  unnecessary  destruction 
of  tissue  with  a  consequent  increase  in  the  discharge,  which 
we  are  endeavoring  to  diminish ;  to  prevent  excessive  inflam- 
matory reaction  by  confining  the  cauterization  to  as  small 
an  area  as  possible  and  what  is  quite  as  important,  to  pre- 
vent giving  the  patient  unnecessary  pain.  This  latter  is 
especially  apt  to  be  severe  if  the  dermal  lining  of  the  external 
auditory  canal  is  at  all  damaged  and  in  cases  where  the  gran- 
ulation tissue  in  part  extends  into  the  canal,  it  is  better  to 
avoid  cauterization  and  depend  entirely  for  its  removal  on 
the  curette  or  cutting  forceps,  as  in  addition  to  the  excessive 
pain  produced,  which  usually  lasts  for  a  day  or  more  after 
the  effects  of  the  local  anaesthetic  have  worn  away,  a  most 
intractable  minute  ulcer  of  the  canal  may  persist  for  a  con- 
siderable time,  despite  the  most  active  treatment.  Another 
method  of  removing  the  excess  of  the  chemical  caustic  from 
that  previously  described  is  by  syringing  out  the  ear  with  an 
alkaline  or  normal  saline  solution  which  has  been  previously 

6 


66  Suppuration  of  the  Middle  Ear. 

sterilized  and  thus  rendering  the  further  action  of  the  cau- 
terant  inert;  it  of  course  not  being  necessary  to  do  this  if 
the  galvano-cautery  should  be  employed.  In  whatever  man- 
ner the  cauterization  is  performed,  always  wait  until  the 
slough  has  thoroughly  separated  from  the  healthy  tissue 
before  another  application  is  made  and  if  necessary  this  may 
be  repeated  several  times,  care  being  taken  at  each  cauteriza- 
tion to  render  the  parts  as  aseptic  as  possible  to  guard  against 
further  infection. 

Synechiotomy,  or  the  division  of  bands  formed  by  gran- 
ulation tissue  growth  in  the  hyperplastic  natural  folds 
of  the  tympanic  mucous  membrane,  is  best  performed  for 
the  evacuation  of  retained  pus  collections,  under  cocaine 
anaesthesia  with  the  patient  in  the  erect  posture,  as  it  is 
essential  in  doing  this  to  have  the  anatomical  landmarks  of 
the  middle  ear  in  as  near  a  natural  relation  as  possible.  The 
operation  is  performed  in  the  same  manner  as  that  described 
for  detaching  an  adherent  tympanic  membrane  from  the 
inner  tympanic  wall  and  with  curved  and  straight  knives 
the  various  bands  or  adhesions  are  divided,  or  if  necessary 
entirely  dissected  away.  It  being  impracticable  to  formu- 
late any  set  procedure  for  this  operation  as  every  case  of 
necessity  presents  an  extreme  degree  of  variation  from  each 
other  and  each  individual  must  be  treated  as  the  particular 
grouping  of  the  adhesions  indicates. 

Polypi,  as  the  result  of  the  excessive  development  in  a 
localized  area  of  the  inflammatory  granulation  tissue,  are 
found  with  a  sufficient  frequency  in  long-standing  cases  of 
chronic  tympanic  suppuration  to  require  some  mention  as 
to  their  effects  upon  the  suppurative  process  and  the  best 
methods  of  eradicating  them.  Their  consistency  and  there- 
fore to  some  extent  its  effect  in  determining  the  manner  of 
their  removal,  depends  upon  the  amount  of  fibrous  tissue 
present  and  from  being  either  hard  or  soft  in  texture,  they 


Treatment  of  the  Mucosa.  67 

may  exceptionally  from  excessive  vascular  development  as- 
sume a  telangiectatic  character  and  thus  be  incapable  of 
removal  except  by  the  cold  snare  gradually  drawn  tight,  so 
that  the  vascular  supply  is  slowly  obliterated.  The  hot  snare 
has  been  also  advised  for  this  purpose,  but  when  used  here 
where  it  is  of  necessity  brought  into  close  contact  with  sur- 
rounding structures,  it  has  been  productive  of  considerable 
destruction  of  tissue,  not  only  from  the  direct  burning  of 
the  parts,  but  also  from  the  irradiation  of  the  heat,  and  under 
no  circumstances  should  the  galvano-cautery  be  used  in  the 
deeper  parts  of  the  external  auditory  canal  or  in  the  cavum 
tympani.  The  question  of  treatment  is  also  greatly  influ- 
enced by  the  nature  of  the  polypus,  that  is  whether  it  is  pedun- 
culated  or  sessile;  if  the  former,  it  may  readily  be  snared, 
but  when  the  growth  springs  from  a  broad  base  it  usually 
requires  curetting  and  cauterization.  These  growths,  while 
increasing  the  tissue  changes  in  the  tympanum,  yet  are  the 
result  of  the  inflammation  of  the  underlying  mucosa  from 
the  suppurating  process  which  is  going  on.  These  polypi 
may  be  either  fibrous,  mucous  or  myxomatous  in  structure, 
the  large  majority,  however,  being  designated  as  the  mucous 
variety,  and  are  readily  removed  with  the  cold  snare.  The 
effect  of  such  a  growth  upon  the  already  existing  puru- 
lent process  being  to  markedly  exaggerate  it  by  increasing 
the  local  irritation,  and  they  also  assume  a  more  serious  im- 
portance when  of  considerable  size  by  obstructing  the  exit 
of  the  purulent  discharge  from  the  middle  ear,  or  in  some 
cases,  where  they  may  even  be  very  small  but  located  so 
as  to  act  as  a  valve  to  the  outflow  of  the  secretion  through 
a  perforation  in  Shrapnell's  membrane,  serious  symptoms  of 
septic  retention  may  be  thus  produced.  When  such  is  the 
case,  the  pus  is  usually  foetid  or  in  part  inspissated  and 
stained  with  blood,  while  the  patient  may  seriously  complain 
of  neuralgic  pains,  vertigo,  tinnitus,  and  even  attacks  of 


68  Suppuration  of  the  Middle  Ear. 

nausea  and  vomiting,  closely  resembling  in  many  respects 
the  symptom  complex  of  intracranial  mischief,  from  possibly 
the  retention  of  but  a  minute  amount  of  this  highly  irritating 
pus.  In  such  cases  not  only  must  the  polypus  be  removed, 
but  the  perforation  in  the  membrana  tympani  should  also 
be  enlarged  to  obtain  free  drainage  and  sometimes  it  is  nec- 
essary to  perform  this  procedure  first,  so  that  sufficient  space 
is  gained  to  allow  of  the  grasping  of  the  growth  by  the  for- 
ceps or  snare. 

As  regards  the  removal  of  polypi  springing  from  the 
tympanic  roof,  the  same  dangers  may  exist  in  their  removal 
as  has  been  pointed  out  in  speaking  of  the  growth  of  granu- 
lation tissue  in  this  locality,  as  in  some  instances  such  extir- 
pation may  be  extremely  hazardous  as  the  polyp  has  devel- 
oped from  the  meninges  and  hangs  down  into  the  tympanic 
cavity,  often  pushed  forward  by  granulation  tissue,  so  that 
no  suspicion  arises  other  than  that  it  is  a  growth  from  the 
tympanic  walls,  and  when  this  takes  place  as  the  result  of 
an  eroded  spot  in  the  tegmen  tympani  or  from  a  congenital 
dehiscence,  pyogenic  organisms  may  thus  gain  access  to  the 
cranial  cavity.  To  prevent  the  recurrence  of  the  growth, 
its  base  after  removal  should  always  be  cauterized,  chromic 
acid  being  preferable  for  this  purpose.  In  addition  to  this 
it  is  essential  to  prevent  as  far  as  possible  the  absorption  of 
pathogenic  microorganisms  from  the  freshly  exposed  sur- 
faces, as  when  the  growth  is  intact  this  danger  is  practically 
nil,  but  after  removal  it  may  be  a  serious  factor  in  the  rapid 
spread  of  the  purulent  inflammation  to  adjacent  structures, 
by  such  absorption  taking  place  through  the  open  and  ex- 
posed vessels.  To  counteract  this  inflammatory  sequela, 
in  addition  to  the  destruction  by  cauterization  of  the  raw 
absorbing  surface,  much  may  be  accomplished  by  the  pre- 
liminary disinfection  of  the  parts  to  be  operated  upon  and 
also  by  careful  after  treatment  with  antiseptic  measures  to 


EXPLANATORY    NOTE    TO    PLATE    X. 


No.  i.  Large  perforation  in  Shrapnell's  membrane  exposing  a  carious  ossicle. 

No.  2.  Large  perforation  of  the  drum  membrane  exposing  the  remains  of  a  carious 

malleus.     Inflammatory  granulations  are  visible  in  the  tympanic  cavity. 
No.  3.  Large  perforation  of  the  drum  membrane  with  an  absence  of  the  handle  of 

the  malleus.    A  polypoid  excrescence  is  seen  protruding  from  the  tympanic 

cavity  into  the  external  auditory  canal. 
No.  4.  Aural  polyp  protruding  from  a  small  perforation  at  the  upper  portion  of  the 

drum  membrane  into  the  external  auditory  canal. 


PLATE  X 


Treatment  of  the  Mucosa.  71 

reduce  to  a  minimum  the  virulency  of  the  organisms  present 
and  to  prevent  the  redevelopment  of  further  growths. 
When  the  attic  is  involved,  and  especially  when  there  is 
caries  of  the  walls,  it  is  not  at  all  uncommon  to  find  a  polypus 
growing  from  some  necrotic  spot  and  projecting  outward 
through  the  perforation  in  the  membrana  tympani,  or  pro- 
ducing bulging  of  the  membrana  in  the  vicinity  of  the  per- 
foration. In  this  location,  or  when  the  polypus  grows  from 
the  lower  tympanic  cavity,  it  becomes  practically  impossible 
to  remove  it  with  the  snare  or  in  fact  any  instrument  until 
the  perforation  has  been  enlarged,  or  in  case  the  growth  is 
quite  large,  until  the  remnants  of  the  tympanic  membrane 
have  in  great  part  been  removed,  when  the  wire  loop  can  be 
placed  about  it  if  it  be  pedunculated.  Where  the  hearing 
is  but  slightly  impaired  and  in  addition  to  the  suppuration, 
the  growth  seems  to  be  the  only  pathological  factor  of  any 
moment  present,  if  it  be  small  it  is  sometimes  possible  with  a 
cotton-tipped  probe  to  push  it  back  into  the  tympanum,  and 
after  ascertaining  the  location  of  its  base,  encircle  it  with 
the  snare  through  the  perforation;  this,  however,  is  not 
always  possible,  but  is  well  worthy  a  trial  where  it  is  not 
desired  to  disturb  the  contents  of  the  tympanum  any  more 
than  is  absolutely  necessary. 

In  addition  to  the  removal  of  these  inflammatory  products 
by  snare,  curette,  cutting  forceps  and  cautery,  they  may, 
when  of  small  size,  often  be  successfully  removed  with  the 
ring  knife,  or  if  of  suitable  size  evulsed  with  forceps,  or 
detached  and  removed  with  the  aural  hook  if  at  all  pedun- 
culated. While  the  mucous  tissues  for  all  these  operative 
procedures  can  be  fairly  well  cocainized,  yet  such  is  not  appli- 
cable to  the  dermal  lining  of  the  auditory  canal,  and  one 
should  exercise  great  care,  especially  in  children  or  nervous 
individuals,  not  to  allow  any  instruments  that  are  being  used 
to  come  into  contact  with  the  walls  of  the  latter,  as  it  renders 


72  Suppuration  of  the  Middle  Ear. 

the  patient  extremely  restless  and  may  necessitate  the  use  of 
general  anaesthesia,  whereas,  if  care  be  used,  such  will  gen- 
erally not  be  necessary.  As  general  principles  in  operating 
upon  these  growths,  one  may  use  the  forceps  to  evulse  the 
masses  if  they  are  small  and  pedunculated  and  in  a  position 
that  room  is  obtainable  to  carry  out  this  procedure,  while  the 
broad-based,  small  and  soft  growths  may  be  crushed  if  it 
does  not  seem  possible  to  remove  them  otherwise,  or  if  any 
contraindications  are  present,  such  as  their  being  situated 
in  a  dangerous  area.  When  the  polypus  or  granulation  is 
quite  firm  and  not  attached  to  the  underlying  parts  by  a  well- 
defined  peduncle,  the  curette  is  preferable  for  its  removal, 
and  if  it  should  spring  from  the  malleus  or  incus,  or  even 
from  the  mucous  surface  of  the  membrana  tympani,  it  is 
always  necessary  to  use  the  snare  if  these  parts  are  not  to 
be  removed.  Should  the  polypus  be  attached  by  a  pedicle 
and  originate  from  the  attic  or  aditus,  it  will  be  necessary, 
in  order  to  grasp  it,  to  bring  it  lower  down  if  possible, 
so  that  it  can  be  readily  reached,  either  with  a  probe,  or 
if  this  fails,  one  of  the  various  forms  of  incus  hooks  may 
often  be  used  successfully  and  then  the  loop  of  the  snare 
suitably  curved  may  be  pushed  up  over  the  growth  until 
its  base  is  reached,  when  it  can  be  readily  removed.  It 
may  be  well  to  mention  in  this  connection  that  for  growths 
situated  lower  down  in  the  tympanic  cavity,  the  snare  can 
be  used  either  by  drawing  tight  the  loop  and  cutting  through 
the  base  of  the  growth,  or  when  it  is  desired  to  evulse  the 
particle  of  tissue,  it  may  be  tightened  until  the  mass  within 
the  loop  is  firmly  grasped,  and  then  by  a  twisting  motion  the 
tissue  is  withdrawn;  this  method  of  evulsion,  however,  can 
only  be  practiced  when  one  is  certain  that  it  will  not  also 
tear  away  and  damage  important  parts.  Where  the  tissue 
to  be  removed  is  so  situated  that  "this  is  liable  to  occur,  it  is 
far  safer  to  use  the  snare  by  drawing  tense  the  loop  until 


Treatment  of  the  Mucosa.  73 

the  tissues  are  cut  away  in  a  smooth  manner.  Undoubtedly 
in  a  considerable  number  of  carefully  selected  cases  of 
chronic  otorrhcea  in  which  the  presence  of  dead  bone  has  been 
excluded,  the  removal  of  granulation  tissue  and  polypi  will 
effect  a  cure. 

Before  concluding  these  remarks  on  the  surgical  treat- 
ment of  this  aspect  of  chronic  aural  suppuration,  it  may  be 
well  to  point  out  that  in  using  the  snare,  the  kind  of  wire 
employed  must  vary  to  suit  the  nature  of  the  tissue  to 
be  removed.  Steel,  copper,  brass,  silver  or  soft  iron  wire  is 
serviceable  if  the  growth  can  be  readily  encircled  by  the  loop ; 
if  this  is  not  the  case  and  the  tissue  is  very  difficult  of 
access,  even  a  very  fine  wire  of  this  nature  is  not  sufficiently 
flexible,  and  slender  brass  wire  is  most  satisfactory.  For 
small  growths  arising  from  the  ossicles  or  tympanic  mem- 
brane, soft  copper  or  iron  wire  is  usually  serviceable,  and  for 
somewhat  larger  polypi  a  thicker  copper  or  silver  wire  may 
be  employed.  When  the  growth  in  part  or  completely  fills 
the  external  canal,  so  that  the  loop  can  barely  be  introduced 
between  it  and  the  wall  of  the  canal,  steel  piano  wire  is  of 
most  value,  as  it  possesses  a  certain  resiliency  which  readily 
adapts  it  to  the  conformation  of  the  base  of  the  growth.  As 
a  rule,  however,  the  most  satisfactory  wire  that  can  be  used 
in  the  great  majority  of  cases,  is  the  fine  brass  wire,  as  it 
is  strong,  possesses  great  flexibility,  and  forms  a  most  satis- 
factory loop  that  will  readily  cut  through  a  firm  fibrous  poly- 
pus or  tuft  of  granulation  tissue  without  the  least  danger 
of  breaking. 

In  practically  all  cases  of  chronic  suppuration,  epithelial 
hyperplasia  takes  place  to  a  greater  or  lesser  degree  and 
dependent  upon  the  extent  and  the  accumulation  of  this  epi- 
thelial debris  or  cholesteatomatous  formation,  will  the  route 
of  operation  in  many  cases  be  absolutely  decided.  With 
the  development  of  these  epithelial  proliferations,  the  squa- 


74  Suppuration  of  the  Middle  Ear. 

mous  cells  lining  the  external  auditory  canal  grow  inward 
through  the  destroyed  area  in  the  tympanic  membrane  and 
develop  more  or  less  rapidly  on  the  inner  tympanic  wall 
and  from  this  point  following  the  course  of  the  air  cells  of 
the  temporal  bone,  the  process  extending  upwards  and  back- 
wards successively  invades  the  attic,  aditus,  antrum  and  in 
extreme  instances,  even  the  mastoid  cells.  This  process,  as 
a  pathological  phenomenon,  may  originate  at  any  point  at  the 
fundus  of  the  canal  where  the  definite  boundary  line  between 
the  dermal  lining  and  the  mucous  membrane  of  the  tym- 
panum has  been  damaged  or  destroyed  and  as  the  course 
of  the  otorrhoea  continues,  the  epithelial  cells  take  on  a 
renewed  activity  and  spreading  out  in  all  directions,  sooner 
or  later  replace  the  mucosa  in  great  part  with  a  dermal 
lining.  This  seems  to  occur  only  when  the  opening  in  the 
membrana  tympani  is  in  relation  with  the  canal  walls,  but 
where  the  perforation  is  centrally  placed,  it  does  not  occur 
unless  the  edges  of  the  opening  become  attached  to  the  inner 
tympanic  wall,  when  the  epithelium  then  is  placed  under 
favorable  conditions  to  extend  to  the  mucosa  with  which  it 
is  in  intimate  contact.  It  is  essential  in  studying  these  cases 
of  chronic  suppuration  with  excessive  epithelial  develop- 
ment to  ascertain  accurately  the  nature  of  the  growth  and 
its  extent,  as  in  this  way  only  will  it  be  possible  to  select  the 
few  cases  where  operation  through  the  canal  will  effect  a 
cure  from  the  larger  number  where  the  parts  must  be  evis- 
cerated by  way  of  the  mastoid  process.  Lucien-Barajas  has 
clearly  shown  this  when  he  states  that  there  are  two  forma- 
tions found  in  the  middle  ear  under  this  name  of  cholestea- 
toma.  One  is  composed  of  granular,  fatty  and  purulent 
masses  of  detritus,  intermixed  with  squamous  epithelial  cells, 
keratin  and  crystals  of  cholesterin,  while  the  other  variety 
is  formed  by  imbricated  nodules  concentrically  arranged 
like  the  layers  of  an  onion.  These  peculiar  nodules,  consist- 


EXPLANATORY    NOTE    TO    PLATE    XI. 


No.  i.  Large  perforation  of  the  drum  membrane  with  caries  of  the  handle  of  the 

malleus.     The  mucous  membrane  lining  the  tympanic  cavity  is  covered  with 

granulations. 
No.  2.  Entire  absence  of  drum   membrane,   malleus   and   incus.     Granulating  areas 

covering  the  mucous  membrane  of  the  tympanic  cavity. 
Nos.  3  and  4.  Remains  of  a  chronic  suppurative  otitis  media.     The  antero-inferior 

and  postero-inferior  quadrants  of  the  drum  membrane  contain  calcareous 

deposits. 


76 


PLATE  XI 


Treatment  of  the  Mucosa.  77 

ing  microscopically  of  large,  flat  endothelial  cells,  polygonal 
in  shape,  the  nuclei  stain  but  faintly,  while  the  masses  con- 
tain a  large  quantity  of  cholesterin.  The  major  portion  of 
such  cases  belong  undoubtedly  to  the  first  group  and  must 
not  be  classed  as  true  cholesteatoma,  nor  should  similar 
masses  be  placed  in  the  same  class  when  composed  of  poly- 
stratifications  of  keratinic  epithelial  cells,  which  develop  after 
inflammatory  dermal  affections  of  the  external  auditory  canal 
and  which  are  horny  or  keratinic  formations. 

On  account  of  endothelial  cells  being  present  at  certain 
areas  in  the  tympanic  cavity,  it  is  possible  in  some  instances 
for  the  affection  to  originate  from  such  places,  but  more 
frequently  it  is  an  extension  inward  of  the  epithelial  elements 
from  the  dermal  lining  of  the  canal  and  whatever  its  source, 
in  order  to  obtain  a  satisfactory  result  it  is  absolutely  essen- 
tial to  select  an  operation  that  will  radically  remove  the 
entire  epithelial  bearing  area  of  the  tympanic  cavity  and 
adjacent  cells.  If  the  process  is  limited,  then  operation 
through  the  canal  will  be  perfectly  suitable,  but  if  at  all 
extensive,  and  this  is  usually  the  case,  such  a  procedure  will 
inevitably  fail.  Practically  always  these  epithelial  masses 
of  the  tympanum  are  associated  with  granulation  tissue  and 
to  a  considerable  extent  also  with  polypi  formation.  When 
this  is  at  all  extensive  and  some  degree  of  purulent  reten- 
tion has  existed  for  a  long  period  of  time,  removal  through 
the  canal  while  it  may  relieve  the  retention,  is  not  productive 
of  beneficial  results  of  any  duration,  although  if  no  symp- 
toms of  mastoid  involvement  can  be  ascertained  and  the  ex- 
perimental nature  of  the  curetting  away  of  these  masses  is 
thoroughly  comprehended  by  the  patient,  one  may  occasion- 
ally in  a  few  cases  obtain  surprisingly  gratifying  results, 
especially  if  the  tympanic  cavity  be  well  cleaned  out  and  all 
foci  of  epithelial  proliferation  be  thoroughly  curetted  as  far 
as  accessible,  with  careful  after  treatment  and  removal  of 


78  Suppuration  of  the  Middle  Ear. 

every  new  particle  of  epithelial  debris  as  soon  as  it  is  recog- 
nized. An  instructive  instance  of  such  a  result  is  re- 
ported by  Tresilian,  where,  in  a  case  of  otitis  suppurativa 
of  thirty-six  years'  duration,  with  associated  multiple  polypi 
and  cholesteatoma  formation,  the  growths  were  removed 
with  forceps  with  recurrence  for  a  time,  but  ultimately  with 
careful  treatment  the  case  was  completely  cured.  The  most 
frequent  sites  for  the  redevelopment  of  the  cholesteatoma 
formation  seems  to  be  on  the  inner  tympanic  wall  and  pos- 
terior surface  of  the  remnants  of  the  tympanic  membrane, 
when  but  a  small  portion  of  it  remains  around  the  circum- 
ference of  the  annulus.  These  parts  should  therefore  be 
carefully  watched  and  on  the  slightest  suspicion  of  the  pres- 
ence of  small  irregular  globular  masses  which  represent 
heaped  up  rapidly  proliferating  epithelial  cells,  they  should  be 
carefully  curetted  away.  When  a  considerable  portion  of 
the  membrana  tympani  remains  with  a  large  central  perfor- 
ation, it  sometimes  happens  that  the  cholesteatoma  develops 
from  the  inner  layer  of  the  membrane  and  escapes  recog- 
nition, and  thus  the  focus  will  remain  to  increase  in  size 
after  the  rest  of  the  tympanic  cavity  has  been  apparently 
cleansed  of  the  masses;  for  this  reason,  therefore,  in  cases 
where  the  condition  is  capable  of  removal  through  the  canal, 
it  is  always  well  to  remove  the  remnants  of  the  drum  as  an 
initial  step  and  thus  prevent  to  this  extent  the  redevelop- 
ment of  this  intractable  phenomena  of  chronic  suppuration. 
While  later  in  the  course  of  the  aural  affection  the  antrum 
becomes  filled  with  cholesteatomatous  masses  and  at  the 
same  time  caries  is  nearly  always  present,  some  good  may  be 
accomplished  in  individuals  refusing  operations  other  than 
through  the  canal,  by  removing  the  malleus  and  incus,  as 
will  be  described  later  and  carefully  curetting  out  the  attic. 
At  least,  this  procedure  will  markedly  aid  in  the  drainage 
of  the  parts  and  may  diminish  to  a  considerable  extent 


Treatment  of  the  Mucosa.  79 

the  purulent  discharge,  but  even  in  somewhat  favorable 
cases  nothing  more  than  this  can  be  hoped  for,  and  inas- 
much as  it  is  impossible  to  thus  remove  all  the  morbid  mate- 
rial, recurrence  will  inevitably  ensue  within  a  comparatively 
short  time.  The  best  procedure  for  the  cure  of  such  condi- 
tions when  the  mastoid  cells  are  not  apparently  involved 
is  the  Stacke  operation. 

The  surgical  treatment  of  cholesteatoma  necessitates  not 
only  the  removal  of  the  epithelial  masses  or  the  definite  neo- 
plasm, but  absolutely  requires  the  thorough  destruction  of 
the  epithelial  bearing  foci  and  scrupulous  attention  to  the 
after  treatment.  In  small  cholesteatoma  of  the  tympanum 
and  involving  to  some  extent  the  antrum,  the  desirable  results 
can  sometimes  be  attained  by  removing  through  the  external 
canal  the  pars  epitympanica  in  part,  with  a  strong  curette  if 
it  be  necrosed  or  with  some  of  the  newer  modifications  of 
chisel- forceps.  In  order  to  avoid  repetition,  the  final  method 
of  removing  the  epithelial  bearing  foci  will  be  described  in 
detail  in  speaking  of  the  mastoid  operation  for  this  affec- 
tion. Volkmann's  sharp  spoon  is  of  great  service  for  scrap- 
ing out  these  masses  through  the  external  auditory  canal, 
and  if  used  under  good  illumination,  with  due  regard  to  the 
surgical  landmarks  of  this  region,  the  epithelial  debris  can 
be  most  effectually  removed.  After  thus  scraping  the  readily 
accessible  morbid  tissue  away,  the  probe  should  be  intro- 
duced both  to  ascertain  the  condition  of  the  newly  exposed 
osseous  tissue  and  also  to  bring  down  into  the  cavity  of  the 
tympanum,  masses  of  the  tissue  which  are  inaccessible  to 
the  spoon.  A  flexible  dull  curette  bent  at  the  proper  angle 
is  often  of  service  for  this  purpose  and  when  all  exposed 
morbid  tissue  has  been  thus  removed,  the  tympanum  should 
be  thoroughly  syringed.  It  is  often  surprising  to  see  the 
amount  of  debris  that  can  be  further  brought  away  in  this 
manner. 


8o  Suppuration  of  the  Middle  Ear. 

In  a  small,  indefinite  percentage  of  these  cases  of  chronic 
otorrhoea,  greater  or  lesser  degrees  of  facial  palsy  will  be 
evident,  probably  only  sufficient  in  amount  to  be  found,  if 
the  same  side  of  the  face  as  the  affected  ear  be  carefully 
examined,  and  it  is  the  opinion  of  the  author  that  this  con- 
dition in  its  very  mild  form  is  more  frequent  than  is  com- 
monly believed.  In  such  cases  the  palsy  is  the  result  of 
slight  pressure  on  the  nerve  from  serous  infiltration  of  its 
sheath,  as  the  result  of  the  tympanum  being  filled  with  gran- 
ulation tissue  and  cholesteatomatous  masses,  and  in  such 
cases  this  is  verified  by  the  removal,  as  has  been  described, 
of  the  morbid  tissue.  The  disappearance  of  the  slight  oblit- 
eration of  the  facial  lines  is  within  a  very  short  time 
coincident  with  the  improvement  of  drainage  thus  effected. 
It  may  usually  be  premised,  as  a  rule,  that  when  the  tym- 
panum is  filled  with  such  material,  the  antrum  is  also  choked 
with  the  epithelial  debris,  so  that  in  well-marked  cases  of 
this  nature  the  removal  of  the  membrana  tympani  and  ossi- 
cles with  the  curetting  as  far  as  possible  of  the  affected  attic, 
will  not  cure  the  purulent  discharge,  but  a  complete  post- 
aural  mastoid  operation  should  be  performed.  Again  in 
contraindication  to  this,  the  presence  of  granulation  and 
carious  bone  in  the  tympanic  cavity  does  not  necessarily 
imply  that  the  antrum  is  involved,  as  occasionally  cases  are 
encountered  where  under  such  conditions  the  antrum  is 
apparently  healthy,  but  in  the  vast  majority  of  cases  where 
the  progressive  suppuration  has  resulted  in  such  changes  in 
the  tympanum,  the  antrum  and  more  distant  mastoid  cells 
will  be  found  to  have  undergone  considerable  morbid  alter- 
ation. 

During  the  course  of  a  chronic  suppuration,  the  relief 
of  pain  by  operative  procedures  through  the  canal  will  oft- 
times  be  the  only  symptom  from  the  view  point  of  the  patient 
that  will  force  him  to  consent  to  operation  directed  towards 


Treatment  of  the  Mucosa.  81 

its  relief  and  at  the  same  time  towards  the  cure  of  the  puru- 
lent discharge.  As  specially  indicated  by  the  pain  of  reten- 
tion, a  small  perforation  in  the  membrana  tympani  should 
be  freely  enlarged  so  that  the  relief  obtained  is  permanent, 
for  if  a  large  opening  be  not  made,  the  tendency  is  towards 
rapid  healing  with  the  return  of  this  symptom  from  the 
recurring  obstruction  to  free  drainage.  If  the  perforation 
be  in  Shrapnell's  membrane,  it  should  also  be  fully  enlarged 
and  with  the  small  spoon,  the  margin  of  the  tympanic  ring 
at  this  point  should  be  removed,  providing  the  external  canal 
be  large  enough  to  allow  of  such  manipulations.  If  relief 
be  not  obtained  in  this  manner  and  the  pain  is  clearly  the 
result  of  retention  of  purulent  material,  either  by  folds  of 
the  mucous  membrane,  granulation  tissue  or  cholesteatoma- 
tous  masses,  these  tissues  should  be  removed,  including  the 
larger  ossicles,  which  may  also  be  diseased,  and  all  points 
favoring  retention  carefully  eradicated.  In  other  words, 
to  obtain  the  successful  accomplishment  of  the  two  factors 
just  mentioned,  all  morbid  tissue  should  be  removed  that 
prevents  in  any  way  the  discharge  of  the  purulent  material 
or  inhibits  free  drainage. 


CHAPTER  IV. 

THE  TREATMENT  OF  THE  OSSICLES. 


THE  TREATMENT  OF  THE  OSSICLES. 

Inasmuch  as  profound  pathological  changes  in  the  mu- 
cosa  of  the  middle  ear  cavity  leaves  its  destructive  impression 
upon  the  ossicular  chain,  certain  indications  thus  become  more 
or  less  evident,  pointing  towards  the  removal  of  one  or  more 
of  these  bonelets  in  order  to  bring  about  the  cessation  of 
the  purulent  otorrhcea.  Before  removing  the  ossicles  in 
any  case,  with  or  without  excision  of  part  of  the  attical  wall, 
one  should  always  have  given  the  patient  the  full  benefit 
of  persistent  and  thorough  local  antiseptic  treatment,  and 
if,  in  spite  of  this,  the  purulent  discharge  still  continues,  the 
question  of  ossiculectomy  should  be  carefully  considered  in 
all  its  aspects.  The  indications  for  removing  the  remains 
of  the  membrana  tympani,  the  larger  ossicles  and  necrosed 
tissue  found  in  the  tympanic  cavity,  will  be  found  to  vary 
in  practically  every  case,  but  as  a  general  rule,  the  operation 
is  usually  indicated  in  chronic  otorrhcea  when  there  is  a 
perforation  of  Shrapnell's  membrane  with  disease  of  the 
epitympanum,  with  definite  caries  of  the  malleus  or  incus, 
and  accompanied  with  more  or  less  impairment  of  hearing. 
When  the  perforation  is  in  this  location,  the  probe  will  prac- 

85 


86  Suppuration  of  the  Middle  Ear. 

tically  always  find  extensive  changes  in  the  attic,  and  as  has 
been  pointed  out  in  the  previous  chapter,  it  is  not  only  the 
question  of  curing  the  chronic  suppuration  that  is  paramount 
in  these  cases,  but  if  the  affected  parts  are  accessible  through 
the  external  canal,  their  removal  is  essential  to  protect  the 
life  of  the  individual. 

As  the  perforation  in  this  locality,  either  above  or  behind 
the  short  process  of  the  incus,  is  the  expression  of  caries  of 
the  head  of  the  malleus  or  incus,  the  removal  of  the  affected 
ossicles  should  be  performed  even  if  the  attic  seems  exten- 
sively diseased,  as  it  will  at  least  delay  a  more  radical  opera- 
tion on  the  mastoid,  and  in  a  number  of  such  cases,  the 
results  as  regards  the  otorrhcea  will  be  eminently  satisfac- 
tory, although,  on  account  of  morbid  changes  in  the  upper 
tympanic  walls,  ossiculectomy  is  of  less  benefit  than  when 
the  active  site  of  the  disease  is  located  in  other  portions  of 
the  tympanic  cavity.  Although  the  operation  is  indicated 
when  the  perforation  is  marginally  situated,  the  chances  of 
success  are  much  lessened  under  such  circumstances.  Often 
the  profuse  attical  suppuration  is  maintained  by  the  caries 
of  the  incus  and  malleus  in  connection  with  the  presence  of 
cholesteatomatous  masses,  inspissated  pus  and  granulation 
tissue,  while  in  other  cases  Shrapnell's  membrane  may  be  en- 
tirely destroyed,  the  only  part  remaining  being  a  small  rem- 
nant attached  to  the  malleus,  with  caries  of  both  the  incus 
and  the  short  process  of  the  former  bonelet  (see  plate  XI). 
Under  these  circumstances,  the  indications  for  the  removal 
of  these  two  ossicles  are  perfectly  clear  and  ossiculectomy 
should  be  performed  without  unnecessary  delay  in  order  that 
the  parts  may  be  freely  drained.  The  presence  of  a  perfora- 
tion in  the  posterior  superior  quadrant  of  the  membrana 
tympani  is  a  fairly  certain  sign  of  ossicular  necrosis,  and 
while  in  some  cases  the  caries  of  the  malleus  or  incus  cannot 
be  accurately  recognized  even  in  the  presence  of  granula- 


The  Treatment  of  the  Ossicles.  87 

tion  tissue,  either  lower  down  or  in  the  epitympanum,  yet 
the  existence  of  this  perforation  is  fairly  accurate  evidence 
of  caries  of  the  incus  and  usually  of  its  descending  process, 
especially  if  the  perforation  extends  in  a  superior  or  inferior 
direction.  When  the  perforation  in  this  location  is  exten- 
sive, the  necrosed  portions  of  the  ossicles  may  be  readily  felt 
and  their  extraction  presents  no  difficulties;  in  some  cases 
even  the  head  of  the  stapes  may  be  visible  and  pus  will  be 
observed  flowing  down  from  beneath  the  upper  border  of 
the  perforation.  In  these  cases  it  is  essential  to  remove 
the  ossicles,  insuring  in  a  moderate  number  of  cases  a  ces- 
sation of  the  suppuration. 

A  further  indication  for  removing  the  ossicles  in  the 
presence  of  an  intractable  suppuration,  is  the  existence  of  a 
small  perforation  in  other  parts  of  the  tympanic  membrane 
than  those  mentioned,  when  retention  of  morbid  products 
is  sufficient  to  make  such  necessary  and  where  incision  has 
failed  to  benefit.  Marked  destruction  in  any  other  part  of 
the  tympanic  membrane  in  which  the  suppurative  process 
proves  rebellious  to  constant  antiseptic  treatment,  is  also 
suitable  for  removal  of  the  malleus  and  incus.  Should  the 
morbid  changes  be  more  extensive,  one  can  only  hope  to 
obtain  a  permanent  cure  by  a  more  radical  operation,  but  in 
a  small  proportion  of  cases,  even  in  the  presence  of  exten- 
sive tissue  changes,  ossiculectomy  is  justifiable  should  for 
various  reasons  a  more  serious  operation  wish  to  be  avoided. 
While  the  site  of  the  perforation  in  the  membrane  will  in 
many  cases  be  sufficient  evidence  of  the  area  of  caries,  espe- 
cially of  the  ossicles,  such  is  not  always  to  be  depended  upon, 
and  it  seems  hardly  possible  to  agree  with  the  observers  who 
claim  that  it  accurately  localizes  the  necrosis,  but  when  pres- 
ent in  Shrapnell's  membrane  it  may  give  great  aid  in  doubtful 
cases  and  in  conjunction  with  other  symptoms,  will  warrant 
one  in  performing  ossiculectomy  in  the  absence  of  positive 


88  Suppuration  of  the  Middle  Ear. 

signs  of  mastoid  caries.  Ossiculectomy  is  most  urgently 
indicated  where  the  suppuration  involves  the  attic  to  a  great 
extent,  on  account  of  the  anatomical  relations  of  this  part, 
as  in  this  immediate  vicinity  are  the  incus,  head  of  the  mal- 
leus, the  intratympanic  muscles  and  ligaments ;  all  of  which 
are  more  or  less  crowded  together,  and  covered  with  the 
numerous  reduplications  of  the  mucous  membrane,  so  that 
unless  the  intratympanic  contents  are  eviscerated,  it  is  im- 
possible to  obtain  free  drainage.  This  is  further  neces- 
sary as  the  swelling  of  the  pus-producing  mucosa  shuts  off 
various  small  chambers  which  become  filled  with  pus  and 
this  in  turn  produces  not  only  ossicular  caries,  but  also 
necrotic  changes  in  the  osseous  walls  of  this  region.  In  such 
cases  both  the  malleus,  incus  and  the  remnants  of  the  mem- 
brana  tympani  should  be  removed,  as  they  are  not  only  in- 
volved in  the  pathological  changes,  but  they  prevent  free 
access  to  the  parts  for  the  essential  cleansing  treatment, 
and  while  the  incus  is  most  frequently  carious,  yet  as  a  rule 
the  malleus  is  also  to  some  extent  involved.  The  removal 
of  the  ossicles  may  also  be  indicated  even  if  the  suppuration 
ceases  for  short  periods  of  time  and  again  returns,  accom- 
panied with  symptoms  of  retention  of  confined  inflammatory 
products.  This  should  be  done  in  such  cases  irrespective  of 
the  condition  of  audition  and  is  more  forcibly  indicated  in 
the  presence  of  masses  of  cholesteatoma  or  such  symptoms 
as  headache  or  frequent  attacks  of  vertigo.  Care  must  be 
taken  to  distinguish  the  two  latter  symptoms  from  corre- 
sponding ones  of  intracranial  origin. 

In  attical  disease  the  removal  of  the  ossicles  is  indicated 
in  order  to  curette  or  cauterize  the  affected  parts  which  can- 
not be  reached  through  the  canal  with  these  bonelets  in  situ. 
Meniere,  for  this  reason,  removes  the  ossicles  and  cleanses 
the  attic  with  a  caustic  solution,  such  as  chloride  of  zinc, 
while,  when  Shrapnell's  membrane  is  perforated  and  the  sup- 


EXPLANATORY    NOTE    TO    PLATE    XII. 


No.  i.  Caries  of  the  head  of  the  malleus. 

No.  2.  Destruction  of  the  head  and  neck  of  the  malleus. 

No.  3.  Caries  of  the  lenticular  process  of  the  incus. 


90 


PLATE  XII 


The  Treatment  of  the  Ossicles.  91 

purative  process  is  limited  to  the  attic  with  but  little  impair- 
ment of  the  hearing,  it  is  sometimes  better  to  open  the  outer 
attic  wall  and  remove  any  diseased  tissue,  as  ossiculectomy  is 
apt  under  such  circumstances  to  seriously  compromise  the 
hearing.  This  can  be  done,  however,  in  but  a  limited  group 
of  cases,  as  in  the  larger  majority,  as  previously  mentioned, 
it  is  necessary  to  remove  the  ossicles  to  obtain  satisfactory 
results;  should  the  former  procedure,  however,  prove  una- 
vailable in  controlling  the  suppuration,  then  the  ossicles 
should  be  removed  as  a  secondary  operation,  as  in  the  major- 
ity of  attical  suppurations  ossiculectomy  offers  the  most  con- 
servative and  helpful  means  of  curing  the  patient.  In  still 
another  and  very  limited  class  of  cases,  where  the  problem 
to  be  solved  is  to  simply  prepare  a  free  exit  for  the  escape 
of  pus  from  the  epitympanic  space,  the  removal  of  the  mal- 
leus, even  if  it  be  found  free  from  caries,  will  be  sufficient, 
but  in  those  cases  where  the  evidence  points  to  a  carious 
process  of  the  walls  of  the  attic  and  aditus,  it  will  also  be 
essential  to  remove  the  incus  in  addition.  Gradingo  advises 
the  removal  of  the  malleus  or  both  larger  ossicles  and  destruc- 
tion by  way  of  the  canal  of  the  postero-superior  osseous 
wall. 

While  it  is  extremely  difficult  to  fix  any  definite  and 
concise  rules  for  the  removal  of  the  ossicles,  as  this  ques- 
tion must  be  decided  by  the  merits  of  each  individual  case, 
yet  as  further  suggestions  along  these  lines,  one  may  remove 
the  ossicles  if  the  attic  is  filled  with  cholesteatomatous  mate- 
rial, or  if  the  greater  portion  of  the  membrana  tympani  is 
destroyed,  while  Barr  advocates  the  removal  of  the  malleus 
preliminary  to  opening  the  antrum.  Following  the  removal 
of  the  malleus,  it  has  seemed  to  be  good  surgical  practice  to 
remove  the  incus  when  it  shows  the  presence  of  caries,  or 
when  for  any  reason,  and  especially  by  previous  intratym- 
panic  manipulations,  this  bonelet  has  been  dislodged  from  its 


92  Suppuration  of  the  Middle  Ear. 

normal  position.  As  regards  the  removal  of  the  ossicles 
where  the  only  conspicuous  symptom  is  more  or  less  puru- 
lent discharge  from  the  middle  ear,  opinions  vary  most  mark- 
edly, but  as  a  rule,  one  should  always  hesitate  to  do  an  ossicu- 
lectomy  until  other  measures  have  been  faithfully  carried 
out  for  a  considerable  period.  It  is  of  interest  to  note  that 
Whiting  advises  that  in  every  case  where  the  discharge  has 
persisted  for  three  months  or  more  during  the  performance 
of  an  operation  for  acute  purulent  otitis  media  and  mas- 
toiditis  the  incus  should  be  removed  as  a  prophylactic  meas- 
ure against  chronic  suppuration.  Ludewig  takes  the  radical 
stand  that  after  one  month  of  treatment  the  malleus  and 
incus  should  be  removed  irrespective  of  the  presence  of 
caries.  It  is  almost  futile  to  fix  any  arbitrary  period  for 
the  performance  of  ossiculectomy,  as  any  operative  pro- 
cedure will  depend  entirely  upon  the  peculiar  features  of 
the  particular  case,  but  speaking  broadly,  the  ossicles  should 
be  removed  as  soon  as  any  of  the  indications  previously  men- 
tioned become  marked  and  then  only  when  the  tissue  destruc- 
tion warrants  its  performance  irrespective  of  the  duration 
of  the  discharge.  They  may  also  be  removed  when  the  sup- 
puration has  become  intractable  in  the  absence  of  subjective 
or  objective  symptoms  pointing  to  involvement  of  the  pneu- 
matic spaces  of  the  mastoid  process,  or  it  should  be  resorted 
to  when  all  other  means  have  failed  to  control  the  discharge 
irrespective  of  the  presence  or  absence  of  any  of  the  various 
indications  mentioned.  It  may  in  some  cases  be  indicated 
simply  to  obtain  free  drainage  even  if  the  tympanic  walls 
are  sufficiently  diseased  to  suggest  a  mastoid  operation  at 
some  future  time,  but  in  which  for  various  reasons  such  an 
operation  must  be  indefinitely  delayed,  or  in  another  class 
where  the  carious  process  is  apparently  localized  to  either 
the  malleus  or  incus.  In  all  cases  of  chronic  suppurative 
otitis  media,  conservatism  should  demand  this  operation  prior 
to  the  performance  of  the  mastoid  operation. 


EXPLANATORY    NOTE    TO    PLATE    XIII. 


No.  i.  Destruction  of  the  long  process  of  the  incus. 

No.  2.  Destruction  of  the  long  and  short  processes  of  the  incus. 

No.  3.  Remains  of  the  body  of  the  incus. 


94 


PLATE  XIII 


The  Treatment  of  the  Ossicles.  95 

However,  in  the  zeal  for  more  radical  operative  pro- 
cedures, ossiculectomy  has  to  some  extent  been  superseded 
by  the  various  forms  of  the  complete  mastoid  operation,  but 
such  in  the  author's  hands  has  often  proved  unnecessary 
in  the  absence  of  definite  mastoid  symptoms,  as  the  excision 
of  the  affected  ossicles  with  the  resultant  better  facilities  for 
treating  the  other  portions  of  the  diseased  tympanum,  will  in 
a  certain  percentage  of  cases  cure  the  suppuration.  Many 
cases  are  thus  susceptible  to  cure  by  the  performance  of 
ossiculectomy,  and  while  it  is  not  always  possible  to  tell 
such  cases  in  advance,  yet  failure  in  no  way  compromises  a 
more  extensive  operation,  but  rather  is  but  a  step  towards 
this  end  if  such  be  necessary.  In  the  differential  diagnosis 
requisite  for  eliminating  the  presence  of  mastoid  alterations 
in  operation  through  the  auditory  canal,  Barrage  and 
Ciarella  have  found  that  the  pus  from  the  antrum  and  mas- 
toid cells  generally  follow  a  definite  course  in  the  tympanic 
cavity  and  may  be  distinguished  from  the  pus  flowing  from 
the  attic  or  derived  from  the  carious  ossicles  by  its  rapid 
reappearance  after  cleansing  the  tympanum,  and  that  it 
always  flows  in  a  straight  line  over  the  inner  wall  of  the 
cavity  from  the  postero-superior  to  the  postero-inferior  seg- 
ment. Thus  passing,  when  the  head  is  held  in  a  vertical 
position  in  front  of  the  round  and  oval  windows,  while  the 
pus  from  the  attic  flows  diffusely  over  the  remains  of  the 
membrana  tympani  on  its  internal  aspect.  When  the  pus 
is  principally  derived  from  the  ossicles,  it  is  scanty  in  amount 
and  reappears  so  slowly  that  its  source  is  readily  distin- 
guished. This  phenomenon  has  proven  of  value  in  selecting 
the  form  of  operation  in  several  obscure  cases  and  based  on 
this  sign  the  authors  quoted  were  able  in  six  cases  to  confirm 
its  diagnostic  value  by  operation,  finding  a  mastoid  empyema 
in  each  case.  When  isolated  caries  of  the  ossicles  can  be 
recognized  and  it  is  of  such  a  degree  that  medicinal  meas- 


96  Suppuration  of  the  Middle  Ear. 

ures  will  apparently  prove  futile,  the  bonelets  should  always 
be  removed,  but  when  in  the  presence  of  an  intractable  sup- 
puration such  is  doubtful,  the  removal  of  the  bones  through 
the  canal  will  at  least  lessen  the  dangers  of  pus  retention. 
Should  caries  of  the  antrum  be  found  associated  with  cho- 
lesteatomata,  the  removal  of  the  ossicles  through  the  canal 
can  be  of  but  little  or  no  service,  and  in  such  cases  it  has 
seemed  better  to  do  the  radical  operation,  as  in  this  way  only 
can  all  the  diseased  tissues  be  reached  and  removed. 

In  summing  up  the  somewhat  numerous  indications  for 
removing  the  ossicles,  the  classification,  as  given  by  Politzer, 
most  clearly  and  concisely  outlines  the  various  classes  in 
which  this  procedure  is  necessary,  the  following  being  the 
special  indications:  (i)  In  suppuration  resisting  treatment 
with  caries  of  the  malleus.  (2)  Obstruction  to  the  flow  of 
pus  from  the  superior  tympanic  space,  and  when  in  spite  of 
treatment,  it  is  occasionally  accompanied  with  partial  swell- 
ing of  the  postero-superior  wall  of  the  meatus.  In  this 
class  are  those  cases  where  the  handle  of  the  malleus  is 
adherent  to  the  promontory  wall  and  in  which  there  is  a 
fistula  in  the  postero-superior  quadrant  of  the  membrana 
tympani,  through  which  flows  curdy,  septic  secretion  from 
the  attic.  (3)  Cholesteatoma  in  the  superior  tympanic  space, 
causing  frequent  relapses  of  the  suppuration.  (4)  Obsti- 
nate suppuration  of  the  external  attic,  with  perforation  of 
Shrapnell's  membrane,  and  in  such  cases  even  if  no  caries 
of  the  malleus  and  incus  be  found,  always  remove  the  ossicles 
if  the  larger  portion  of  the  membrana  tympani  is  destroyed 
and  only  a  small  remnant  is  connected  with  the  malleus.  (5) 
Granulations  in  the  attic,  recurring  and  growing  into  the 
tympanic  cavity  and  meatus,  especially  if  pus  retention  be 
also  present,  but  in  this  class  the  cure  is  rarely  permanent, 
and  in  the  large  majority  of  such  cases  the  radical  operation 
has  to  be  performed  sooner  or  later  to  obtain  a  lasting  result. 


The  Treatment  of  the  Ossicles.  97 

Naturally,  ossiculectomy  presents  certain  limitations,  as 
a  certain  proportion  of  chronic  suppurative  cases  cannot  be 
relieved  by  this  measure,  but  require  more  extensive  removal 
of  the  largely  diseased  areas.  Facial  paralysis  resulting 
from  operation  through  the  canal  but  rarely  occurs.  As 
regards  the  limitations  of  ossiculectomy,  one  can  expect  it 
to  be  of  great  value  when  properly  performed  in  selected 
cases,  but  it  should  not  be  done  simply  on  account  of  the 
presence  of  an  aural  discharge,  for  if  this  should  be  very 
mild  or  unirritating  and  has  had  no  apparent  effect  upon 
the  hearing,  topical  applications  directed  to  the  mucosa  of  the 
tympanum  will  result  in  a  cessation  of  the  discharge.  One 
may  roughly,  yet  quite  satisfactorily,  divide  cases  of  chronic 
suppuration  into  three  classes :  firstly,  those  in  which  the  sup- 
puration is  the  result  of  carious  changes  of  the  ossicles  and 
in  which  the  bonelets  should  be  removed.  Secondly,  cases 
in  which  the  predominating  feature  is  the  change  occurring 
in  the  walls  of  the  tympanum,  when  ossiculectomy  may  or 
may  not  be  performed,  the  determining  factor  being  the 
degree  of  the  bone  involvement  and  its  extension  into  the 
antral  cavity  or  not.  While  the  third  class  positively  pro- 
hibits evisceration  in  this  manner,  as  it  comprises  that  group 
in  which  the  purulent  discharge  is  the  consequence  of  morbid 
changes  in  the  antrum  and  mastoid  cells  and  the  removal 
of  the  ossicles  alone  will  in  no  way  limit  the  course  of  the 
disease,  but  may  be  performed  previously  to  the  radical  oper- 
ation in  order  to  temporarily  aid  free  drainage,  when  both 
malleus  and  incus  should  be  removed. 

Caries  and  necrosis,  as  related  to  the  surgical  treatment 
of  this  condition,  may  be  limited  to  the  ossicles  alone,  or,  as 
is  more  frequent,  may  also  involve  the  adjacent  bony  walls 
to  a  greater  or  lesser  extent.  It  may  still  further  be  limited 
to  the  malleus  alone,  or  again  the  incus  only  may  be  involved 
in  the  destructive  process  and  in  some  cases,  although  it  is 


98  Suppuration  of  the  Middle  Ear. 

not  commonly  found,  the  entire  ossicular  chain  may  be 
carious.  The  knowledge  of  the  parts  involved  in  the  carious 
changes  is  important,  as  upon  it  depends  the  form  of  opera- 
tion employed  to  relieve  the  chronic  aural  suppuration,  and 
while  the  body  of  the  incus,  in  connection  with  the  head  of 
the  malleus,  are  most  frequently  involved,  yet  when  but  one 
bonelet  is  affected,  the  incus,  as  will  be  mentioned  later,  is 
the  one  usually  involved,  the  stapes  rarely  being  affected  to 
any  degree  unless  in  connection  with  well-marked  necrotic 
changes  of  the  other  ossicles  and  usually  of  the  bony  walls. 
When  both  the  larger  ossicles  are  involved,  the  carious 
process  commonly  originates  at  the  malleo-incudal  articu- 
lation and  extending  deeply  into  the  bony  structures  of  these 
ossicles,  until,  in  severe  cases,  only  an  irregular  minute  piece 
of  bone,  representing  the  fused  malleus  and  incus,  may  be 
found,  usually  embedded  in  a  mass  of  granulation  tissue  (see 
plates  XII  and  XIII).  Again,  the  head  of  the  malleus  may 
be  totally  destroyed  and  the  handle,  if  found  at  all,  presents 
the  appearance  of  terminating  abruptly  above  the  short 
process.  As  long  as  the  manubrium  is  protected,  even  by 
a  remnant  of  the  membrana  tympani,  it  usually  remains 
intact,  but  when  this  also  becomes  destroyed  and  the  suppu- 
rative  inflammation  extends  to  the  periosteal  layer,  this 
osseous  process  gradually  undergoes  absorption  and  may 
entirely  disappear.  As  a  rule,  in  these  cases,  the  lower  part 
of  the  manubrium  alone  is  completely  disintegrated,  although 
the  upper  portion  may  feel  rough  to  the  probe,  but  it  is  quite 
uncommon  to  observe  the  manubrium  so  completely  destroyed 
that  only  the  short  process  and  the  head  of  the  malleus 
remain.  While,  as  before  noted,  the  incus  is  more  frequently 
involved  than  the  other  ossicles,  the  long  process  is  destroyed 
more  often  than  the  other  anatomical  divisions  of  this  bone, 
and  it  may  be  simply  eroded  by  the  absorption  produced  by 
the  constant  passage  of  irritating  pus  flowing  over  it,  or, 


The  Treatment  of  the  Ossicles.  99 

again,  as  is  more  frequent,  this  process  may  be  entirely  de- 
stroyed by  caries.  The  stapes,  from  its  more  or  less  pro- 
tected position,  is  but  rarely  involved,  and  from  its  resistance 
to  the  carious  process,  which  it  seems  to  possess  to  a  remark- 
able degree,  it  is  usually  found  to  be  intact,  although  the 
capitellum  and  one  or  both  crura  in  part  may  be  destroyed 
and  only  the  foot  plate  will  be  found  remaining  in  the  oval 
window. 

Coincident  with  or  previous  to  the  destruction  of  the  ossi- 
cles in  part  or  whole,  the  continued  suppuration  may  pro- 
duce loosening  or  complete  separation  of  their  various  artic- 
ular attachments,  either  by  the  absorption  of  their  ligaments 
or  by  a  more  rapid  destruction  which  especially  occurs  in 
cachectic  individuals.  This  displacement  of  the  malleus  and 
incus  particularly  may  also  result  from  direct  pressure  ex- 
erted upon  them  by  masses  of  granulation  tissue,  or  it  may 
also  occur  when  the  surfaces  of  the  bone  in  relation  to  the 
articulations  becomes  necrotic  and  granulation  tissue,  spring- 
ing from  these  areas,  erodes  and  penetrates  directly  into  the 
delicate  joints.  The  joint  most  frequently  affected  in  this 
manner  during  the  course  of  a  chronic  suppuration  is  that 
between  the  incus  and  stapes,  and  this  change  so  frequently 
encountered  in  the  surgical  treatment  of  this  condition  exer- 
cises a  most  important  bearing  upon  the  modifications  neces- 
sary in  performing  ossiculectomy  in  such  cases.  When  the 
articulation  between  the  malleus  and  incus  has  been  de- 
stroyed, the  latter  ossicle  immediately  loses  its  topograph- 
ical position  in  the  tympanum,  and  it  may  either  be  pushed 
into  the  antrum,  where  it  is  practically  inaccessible  by  opera- 
tion through  the  canal,  or  it  is  often  discharged  from  the 
canal  during  cleansing  of  the  ear,  so  that  unless  this  con- 
dition be  recognized  much  time  will  be  lost  in  searching  for 
it,  when  only  the  malleus  and  stapes  remain.  The  malleus 
also  changes  its  position  when  a  separation  of  this  joint 


ioo  Suppuration  of  the  Middle  Ear. 

occurs  and  it  usually  swings  about  on  its  axis,  so  that  it  is 
retained  in  this  altered  position  by  the  tendon  of  the  tensor 
tympani  muscle,  or  by  its  anterior  ligament,  or  both,  although 
the  latter,  in  cases  of  this  severity,  may  also  in  great  part 
be  destroyed.  In  extreme  cases,  especially  when  a  tuber- 
cular element  is  present  or  the  degree  of  caries  and  necrosis 
is  such  that  operation  through  the  canal  is  contraindicated, 
the  ligamentous  tissue  supporting  the  foot  plate  of  the  stapes 
in  the  oval  window  may  also  be  destroyed  and  the  stapes  may 
be  entirely  displaced  spontaneously,  or  the  slightest  touch 
with  the  probe  will  be  sufficient  to  dislodge  it.  In  such  cases, 
the  various  intratympanic  ligaments,  muscles  and  redupli- 
cations of  the  mucosa  are  also  in  great  part  destroyed,  so 
that  the  ossicles  have  either  become  entirely  obliterated  or 
have  been  washed  away  in  the  profuse  purulent  discharge, 
and  of  course  in  such  cases  the  radical  mastoid  operation  is 
the  only  measure  which  holds  out  the  best  chance  of  a  per- 
manent cure  of  the  suppuration. 

As  the  malleus  and  incus,  with  their  articulation,  are  so 
often  carious,  it  is  somewhat  difficult  to  always  obtain  satis- 
factory evidence  of  the  presence  of  disintegrating  changes 
in  these  bones,  but  if  there  is  a  defect  in  the  anterior  wall  of 
the  attic,  or  a  perforation  in  Shrapnell's  membrane,  the 
probe  passed  through  either  of  these  may  be  able  to  detect 
roughened  bone  unless  the  caries  is  located  on  the  internal 
aspect  of  these  ossicles,  where,  of  course,  it  is  inaccessible. 
In  many  cases  the  diagnosis  previous  to  ossiculectomy  cannot 
be  definitely  proven,  but  the  symptoms  of  persistent  sup- 
puration with  a  perforation  in  the  posterior  segment  of  the 
membrana  tympani,  as  before  described,  is  strong  evidence 
of  caries  in  this  situation,  and  if,  in  addition  to  this,  puru- 
lent or  cheesy  material  is  found  coming  from  the  attic  and 
granulation  tissue  in  this  region  rapidly  recurs  after  removal, 
one  is  absolutely  justified  in  considering  that  caries  is  pres- 
ent and  in  removing  both  the  larger  ossicles.  As  has  been 


The  Treatment  of  the  Ossicles.  101 

pointed  out  by  several  observers,  the  ossicles,  as  regards 
the  presence  of  caries  and  necrosis,  bear  a  marked  similarity 
to  the  long  bones  of  other  portions  of  the  body,  as  their 
articular  extremities,  similar  to  the  epiphyses  of  the  long 
bones,  are  most  often  and  primarily  involved  in  the  carious 
process,  while  their  more  slender  processes  are  much  more 
frequently  affected  by  the  necrotic  process,  as  is  also  the 
diaphysis  of  long  bones.  In  regard  to  the  relative  frequency 
of  the  involvement  of  the  parts  in  these  destructive  processes, 
the  handle  of  the  malleus  and  the  short  process  of  the  incus 
most  frequently  show  necrotic  changes,  and  while  these  parts 
are  at  first  being  more  or  less  gradually  disintegrated,  the 
articular  surfaces  of  both  the  larger  ossicles  may  show  but 
a  very  scant  loss  of  osseous  tissue  or  may  for  a  considerable 
time  at  least  present  no  evidence  at  all  of  necrotic  change. 

As  the  result  of  the  various  pathological  changes  which 
take  place  in  the  tympanic  cavity  and  so  markedly  alter  the 
relations  of  its  contents,  the  technique  of  ossiculectomy  must 
vary  almost  in  every  case  to  suit  the  particular  conditions 
present.  Granulation  tissue,  epithelial  masses  and  inspis- 
sated purulent  material  may  fill  the  cavity  so  that  all  the 
landmarks  are  abolished  and  even  the  ossicles,  as  previously 
mentioned,  may  be  absent,  from  destruction,  or  be  repre- 
sented only  by  an  irregular  necrotic  fragment  (see  plate  XI). 
In  other  cases  calcification  has  taken  place,  so  that  consider- 
able force  is  essential  in  their  removal,  while  again,  adhesions 
between  the  malleus  and  incus  and  the  tympanic  walls  is 
somewhat  frequently  encountered,  so  that  it  is  extremely 
difficult  to  even  locate  the  irregular  bony  masses  representing 
the  ossicles  in  order  to  successfully  remove  them.  It  is  nec- 
essary, therefore,  in  describing  the  various  methods  for  their 
removal,  to  explain  the  operation  as  if  the  ossicles  were  in 
their  normal  positions  with  their  articulations  intact,  and 
then  as  far  as  possible  make  clear  the  various  modifications 
essentially  concerned  in  their  altered  condition. 


102  Suppuration  of  the  Middle  Ear. 

In  performing  ossiculectomy,  anaesthesia,  either  local  or 
general,  is  always  essential ;  the  choice  of  anaesthetic  depend- 
ing entirely  upon  the  amount  of  tissue  to  be  removed  and 
the  extent  of  damage  to  the  osseous  walls  of  the  tympanic 
cavity.  When  the  membrana  tympani  is  in  great  part  de- 
stroyed, so  that  free  ingress  to  the  parts  may  be  obtained, 
the  canal  of  ample  size  and  the  patient  well  under  control, 
with  but  a  few  bone  fragments  or  possibly  the  malleus  and 
incus  to  be  removed  without  the  walls  requiring  extensive 
curetting,  local  anaesthesia  with  cocaine  in  from  5  to  20  per 
cent,  solution  will  be  most  satisfactory.  As  the  various  fresh 
areas  of  tissue  are  exposed,  they  must  be  cocainized,  as  it 
is  essential  that  no  pain  be  inflicted,  as  the  head  of  the 
patient  must  be  held  absolutely  immobile,  and  if  there  is 
much  nervousness,  general  anaesthesia  will  have  to  be  em- 
ployed. The  cocaine  may  be  used  in  conjunction  with 
adrenalin  chloride,  so  that  bleeding  is  reduced  to  the  mini- 
mum amount.  The  head  of  the  patient  is  inclined  and  the 
canal  of  the  ear  filled  with  a  I  to  1000  adrenalin  solution; 
this  is  allowed  to  remain  for  about  five  minutes,  when  the 
parts  will  become  blanched,  then  the  cocaine  solution  of  the 
strength  desired  is  used  in  the  same  manner  and  allowed  to 
remain  about  fifteen  minutes,  when  the  parts  are  dried  and 
both  the  solutions  again  applied  in  the  order  noted,  when, 
after  thorough  drying,  the  parts  are  ready  for  operation. 
As  one  is  never  sure  of  the  amount  of  tissue  destruction,  or 
if  dangerous  areas  may  be  exposed  until  the  operation  is 
well  under  way,  and  as  it  is  a  serious  problem  in  curetting 
a  mass  of  granulation  tissue  under  cocaine  anaesthesia  to 
find  that  their  removal  has  exposed  the  dura  through  a  cleft 
in  the  tegmen  tympani,  it  is  better  in  the  majority  of  cases 
where  granulation  tissue,  cholesteatoma  masses  and  evi- 
dences of  extensive  caries  are  present,  to  use  a  general  anaes- 
thetic, as  the  patient  can  be  better  kept  under  the  absolute 


The  Treatment  of  the  Ossicles.  103 

control  of  the  operator.  The  question  of  anaesthesia  must 
of  necessity  be  separately  decided  in  each  individual  case 
that  comes  to  operation,  and  while  local  anaesthesia  is  always 
preferable  as  a  general  principle  if  the  conditions  allow,  yet 
general  narcosis  must  be  employed  in  the  larger  number  of 
cases  operated  upon.  Nitrous  oxide  has  been  employed  for 
this  purpose  in  some  instances,  and  while  with  its  use  one 
can  have  the  patient  in  an  upright  position,  which  is  a  great 
desideratum,  and  possessing  as  it  does  the  advantages  of 
rapidity  of  anaesthesia,  rapid  recovery  without  nausea  fol- 
lowing its  administration  and  the  practical  elimination  of 
danger,  yet  its  effects  are  too  transitory. 

The  posture  of  the  patient  should  be  such  that  the  posi- 
tion of  the  membrana  tympani  be  kept  as  nearly  normal  as 
possible  in  relation  to  the  natural  position  of  the  patient's 
head  when  in  an  upright  position,  so  that  the  normal  topog- 
raphy of  the  parts  will  be  maintained,  the  ideal  position  of 
the  patient  being  the  upright  posture,  with  the  head  firmly 
fixed  in  position.  With  local  anaesthesia  this,  of  course,  is 
always  possible,  but  the  reverse  is  the  case  under  general 
narcosis,  and  when  a  general  anaesthetic  is  employed,  the 
patient  of  necessity  being  in  the  recumbent  position,  the 
shoulders  should  be  elevated  so  that  the  head  can  be  turned 
in  any  direction  desired.  Upon  no  point  does  the  success 
of  ossiculectomy  depend  so  much  as  upon  proper  illumina- 
tion, as  it  is  absolutely  impossible  and  extremely  dangerous 
to  attempt  to  remove  the  ossicles  unless  the  parts  are  well 
illuminated,  so  that  every  step  of  the  operation  can  be  seen. 
With  local  anaesthesia  the  head  mirror  and  gas  illumination 
may  be  employed,  but  when  general  narcosis  is  employed, 
this  is  impossible  and  the  electric  head  light  should  be  used. 
This  is  the  more  satisfactory,  however,  irrespective  of  the 
anaesthetic  or  posture  of  the  patient,  and  with  a  good  photo- 
phore  it  is  perfectly  possible  to  observe  just  what  is  being 


104  Suppuration  of  the  Middle  Ear. 

done  during  all  the  steps  of  the  operation,  as  the  light  can  be 
focussed  to  the  point  desired,  the  rays  falling  in  a  direct  line. 
As  essential  as  any  other  factor  in  obtaining  successful 
results  in  ossiculectomy,  is  the  method  adopted  for  the  con- 
trolling of  the  bleeding  which  necessarily  ensues  when  in- 
cisions are  made  into  the  softer  tissues  and  especially  when 
granulation  tissue  is  removed.  Adrenalin  chloride  is  par 
excellence  the  most  satisfactory  haemostatic  that  we  possess, 
and  when  applied  as  indicated,  with  in  addition  its  free  use 
during  the  entire  course  of  the  operation,  it  will  in  the  ma- 
jority of  cases  render  the  operation  practically  bloodless 
and  remove,  to  a  great  extent,  the  rapid  filling  of  the  tym- 
panum with  blood  after  the  first  few  incisions  have  been 
made,  and  which,  previous  to  its  introduction,  forced  the 
operator  to  an  undue  haste  and  kept  him  constantly  mopping 
the  blood  away  with  cotton  tufts.  Thus,  when  freely  used, 
it  both  simplifies  and  shortens  ossiculectomy  by  reducing  the 
bleeding  to  a  minimum  and  at  the  same  time  allows  one  a 
greater  space  for  the  various  manipulations  by  its  marked 
action  in  shrinking  the  tissues.  The  effect  of  the  cocaine 
anaesthesia  seems  as  well  to  be  intensified  by  the  combina- 
tion with  adrenalin.  The  hemorrhage  may  also  be  con- 
trolled by  packing  the  tympanum  and  canal  with  small  strips 
of  iodoform  or  sterile  gauze,  either  dry  or  soaked  in  adrena- 
lin solution.  A  semirecumbent  position  of  the  patient  aids 
to  some  slight  extent  in  preventing  excessive  bleeding.  The 
strips  of  gauze  should  be  carried  well  into  the  tympanic  cav- 
ity and  firmly  pressed  against  the  bleeding  areas  if  such  be 
visible,  a  large  number  of  small  pieces  being  used  in  pref- 
erence to  one  or  more  larger  ones.  That  the  bleeding  may 
even  in  the  hands  of  an  experienced  operator  be  of  sufficient 
severity  to  interfere  with  the  operation  has  been  shown  by 
Schmiegelow,  who,  in  a  case  where  he  was  endeavoring  to 
remove  the  malleus,  encountered  such  severe  and  obstinate 
bleeding  that  he  was  forced  to  desist  from  operation. 


The  Treatment  of  the  Ossicles.  105 

The  necessary  instruments  most  frequently  employed 
consist  of  a  speculum,  and  it  is  essential  that  the  largest  that 
will  comfortably  fit  the  canal  should  be  used  for  this  pur- 
pose, a  number  of  applicators,  previously  wound  with  sterile 
cotton,  delicate  forceps  and  a  snare,  the  two  latter  being  to 
seize  the  ossicles  after  their  attachments  have  been  severed 
and  remove  them  from  the  tympanic  cavity.  The  knives 
used  for  this  purpose  should  be  both  sharp-  and  probe- 
pointed,  curved  and  straight,  and  small  angular  knives  with 
the  sharp  edge  bent  close  to  the  point  both  at  an  obtuse  and 
at  a  right  angle.  The  knives  recommended  for  this  purpose 
by  Bench  are  quite  satisfactory.  They  are  made  from  small 
steel  wire  and  the  shaft  of  each  knife  screws  into  a  small 
handle,  it  being  advisable  to  have  each  instrument  with  its 
handle  attached  rather  than  a  universal  handle.  The  shank 
of  the  knife  is  malleable,  so  that  it  can  be  bent  at  any  angle 
desired,  yet  has  sufficient  firmness  not  to  bend  when  cutting 
through  the  tympanic  tissues.  The  question  as  to  whether 
the  shaft  of  the  knife  is  straight  or  forms  an  angle  with  the 
handle  bears  no  relation  to  its  value  for  the  purposes  men- 
tioned, as  the  selection  of.  a  matter  of  this  nature  depends 
entirely  upon  the  personal  taste  of  the  operator,  although, 
as  a  rule,  the  straight  handled  knives  are  more  readily  man- 
aged and  do  not  get  in  the  visual  field  as  one  would  com- 
monly suppose.  It  is  also  necessary  to  have  various  small 
sizes  of  curved  and  blunt  hooks  and  also  sharp  hooks,  while 
straight  and  angular  sharp  spoons  are  also  essential.  When 
removing  the  anterior  attic  wall  cutting  forceps  or  chisels 
are  necessary  and  for  cleaning  out  this  part  various  curettes 
may  be  used,  Lake's  being  quite  valuable  for  this  purpose. 
It  is  crochet-shaped  and  by  its  use  small  particles  of  the 
necrotic  ossicles,  and  especially  the  incus,  can  be  readily 
removed.  As  advised  by  its  originator,  it  is  passed  into  the 
attic  after  the  malleus  has  been  removed  and  there  occupies 


io6  Suppuration  of  the  Middle  Ear. 

the  place  made  vacant  by  the  head  of  this  bone,  the  handle 
is  then  rotated  forward  and  grasps  the  incus  or  any  rem- 
nants that  may  be  found  and  by  a  forward  and  downward 
motion,  the  bone  is  dislodged  into  the  tympanum  or  removed 
entirely  in  the  loop  of  the  instrument.  It  is  unnecessary  to 
give  a  detailed  description  of  these  various  instruments,  as 
they  can  be  obtained  in  various  forms  and  in  describing  in 
detail  the  removal  of  the  separate  ossicles,  the  use  of  the 
various  instruments  will  also  be  described. 

The  first  step  necessary  to  the  removal  of  the  ossicles 
is  the  dissecting  away  of  the  remnants  of  the  membrana 
tympani,  and  this  may  be  done  by  one  of  several  methods, 
depending  upon  the  conditions  present.  If  a  large  remnant 
of  this  membrane  remains,  it  is  incised  near  its  periphery 
with  a  straight  narrow  knife  which  may  be  pointed  or 
rounded  at  its  end,  and  as  far  as  possible  the  incision  should 
be  placed  in  close  connection  with  the  tympanic  ring,  while 
the  membrane  should  be  entirely  removed.  When  adhesions 
are  present  between  the  membrana  tympani  and  the  walls  of 
the  cavity,  they  should  be  dissected  away  with  straight  or 
angular  knives,  as  may  be  necessary  in  the  individual  case, 
and  with  a  straight  knife  the  membrane  is  incised  around 
its  entire  periphery  about  a  line  from  its  attachment  to  the 
annulus  tympanicus.  This  leaves  it  free  in  all  respects  ex- 
cept its  central  attachment  to  the  manubrium  and  this  is 
removed  by  using  the  same  knife  and  continuing  the  incisions 
down  on  each  side  of  the  malleus,  where  they  meet  at  its 
tip,  and  thus  completely  sever  the  membrane  from  all  its 
attachments,  when  it  is  then  removed  with  forceps.  This 
must  be  modified  by  omitting  the  incisions  along  the  manu- 
brium and  lower  arc  of  the  circumference  of  the  annulus 
in  those  cases  where  the  inferior  two-thirds  of  the  membrana 
tympani  has  been  entirely  destroyed,  and  where  the  remains 
of  Shrapnell's  membrane  is  hyperplastic  and  the  seat  of  an 


The  Treatment  of  the  Ossicles.  107 

increased  vascular  supply,  so  that  it  appears  to  be  firmly  in 
contact  with  the  ossicles  and  seems  to  render  them  invisible. 
Under  these  circumstances  the  landmarks  may  be  entirely 
obliterated  or  the  short  process  of  the  malleus  and  the  promi- 
nent foreshortened  horizontally  lying  portion  of  the  manu- 
brium  may  be  seen,  the  tip  of  the  latter  often  having  formed 
an  adhesion  with  the  superior  portion  of  the  internal  tym- 
panic wall.  In  other  cases  in  which  the  membrane  has 
previously  been  apparently  destroyed,  one  may  find  only  a 
thin  cicatricial  membrane,  especially  in  the  superior  seg- 
ment, which  reveals  through  it  the  articulation  of  the  incus 
and  stapes  if  it  has  not  already  been  destroyed,  which  is  not 
at  all  uncommon  in  such  cases  (see  plate  VIII,  Fig.  2).  This 
membrane  must  be  dissected  away  by  the  peripheral  incision, 
and  if  it  be  found  impossible  to  remove  it  from  its  attachment 
to  the  malleus,  it  should  be  allowed  to  remain  until  this  ossicle 
is  removed,  when  it  will  come  away  at  the  same  time.  When 
only  a  small  area  of  the  tympanic  membrane  has  been  de- 
stroyed, the  peripheral  attachments  of  the  membrane  may 
be  cut  from  below  upwards  by  introducing  the  knife  through 
the  perforation  and  commencing  the  incision  from  this  point. 
This,  however,  cannot  be  well  done  if  firm  adhesions  exist 
between  the  membrane  and  the  tympanic  wall,  but  if  these 
are  not  present,  and  such  is  the  case  in  a  few  instances,  this 
method  is  very  serviceable.  Should  numerous  adhesions  be 
present  they  may  cause  excessive  annoyance  by  their  bleed- 
ing when  severed ;  it  is  far  more  advisable  to  incise  the  supe- 
rior segment  of  the  membrana  at  first,  and  instead  of  com- 
mencing at  the  perforation,  anterior  and  posterior  incisions 
are  made  from  above,  both  of  which  are  continued  into  the 
perforation. 

Again,  the  remnants  of  the  membrane  may  be  removed 
by  entirely  ignoring  the  perforation  present  and  inserting  a 
straight-pointed  knife  into  it  immediately  above  the  short 


io8  Suppuration  of  the  Middle  Ear. 

process.  From  this  point  the  incision  is  made  backwards, 
dividing  the  membrane  as  closely  as  possible  to  the  tympanic 
ring,  care  being  taken  at  the  same  time  that  the  knife  is 
inserted  not  too  deeply  into  the  tympanic  cavity  in  order  not 
to  damage  the  ossicles  or  their  articulations.  The  anterior 
attachments  of  the  tympanic  membrane  are  then  incised  in 
the  same  manner  and  it  will  be  found  that  in  this  way  bleed- 
ing has  been  reduced  to  a  minimum  and  the  malleus  can  be 
readily  removed.  In  whatever  method  is  adopted  in  the 
individual  case,  it  should  always  be  endeavored  to  remove 
as  much  of  the  membrane  as  possible,  as  it  is  apt  to  cover  a 
necrosed  area  at  the  margin  of  the  tympanum,  and  if  any 
membrane  be  left,  this  carious  spot  is  very  apt  to  remain 
undiscovered,  although  there  may  be  a  single  exception  to 
this,  and  that  is  in  cases  where  the  extreme  lower  part  of  the 
membrane  is  healthy  and  the  probe  shows  that  the  osseous 
tissue  in  its  immediate  vicinity  is  also  sound,  then  a  small 
portion  may  be  allowed  to  remain  in  this  situation  in  order 
that  it  may  act  as  a  basis  for  the  epidermization  of  the  tym- 
panic cavity,  so  necessary  to  the  complete  cure  of  the  sup- 
puration. 

While  evidence  of  caries  of  the  malleus  is  plainly  obtain- 
able in  the  vast  majority  of  cases  in  which  this  ossicle  is 
diseased  when  the  perforation  embraces  the  larger  portion 
of  the  tympanic  membrane,  yet  in  those  cases  where  Shrap- 
nell's  membrane  alone  is  the  seat  of  a  perforation,  one  can 
not  be  always  sure  of  the  involvement  of  the  malleus, 
although  the  probable  presence  of  caries  may  be  fairly  well 
surmised  under  these  conditions  if  the  discharge  seems  to 
be  excessive  in  this  region  and  escapes  through  the  perfora- 
tion in  this  location.  The  studies  of  Ferreri  are  of  impor- 
tance in  this  connection,  as  he  found  in  thirty-eight  cases 
of  chronic  tympanic  suppuration  that  the  lesions  of  the  mal- 
leus and  incus  were  very  slight  and  in  the  main  consisting 


EXPLANATORY    NOTE    TO    PLATE    XIV. 


A  schematic  drawing  demonstrating  the  removal  of  the  malleus,  with  the  forceps 
m  position.     The  upper  lateral  wall  of  the  tympanum  showing  areas  of  necrosis. 


no 


PLATE  XIV 


The  Treatment  of  the  Ossicles.  1 1 1 

of  an  atrophic  process,  as  shown  by  the  rarefaction  of  the 
bony  tissue  and  a  diminution  in  volume  of  part  or  all  of  the 
ossicle,  while  in  several  of  the  cases  the  atrophied  bone  was 
surrounded  by  granulation  tissue.  In  another  series  of 
thirty-seven  cases,  it  was  found  in  twenty-three  that  there 
were  circumscribed  or  diffuse  caries,  and  as  a  rule  the  carious 
ossicles  were  surrounded  with  masses  of  granulations.  The 
carious  area  sometimes  involved  one  of  the  articular  sur- 
faces and  then  produced  ankylosis  between  the  malleus  and 
incus,  and  in  every  instance  where  the  lesion  of  the  ossicle 
was  in  any  way  serious,  it  was  always  secondary  to  a  diffu- 
sion of  the  inflammation  which  had  primarily  attacked  the 
mucosa  of  the  tympanic  cavity. 

Previous  to  the  removal  of  the  malleus  the  tensor  tym- 
pani  muscle  must  be  severed  at  its  attachment  to  the  ossicle, 
and  this  is  best  performed  by  means  of  a  delicate  sickle- 
shaped  knife  or  one  shaped  like  a  small  spade,  bent  at  an 
angle  with  the  shaft.  The  end  of  the  knife  is  carried  under 
the  anterior  or  posterior  fold  as  may  be  most  convenient  in 
the  particular  case,  when  depending  upon  its  position  in 
relation  to  the  malleus,  it  is  gently  rotated  forward  or  back- 
ward posterior  to  the  bonelet,  until  the  tendon  of  the  muscle 
is  recognized  by  the  knife  coming  into  contact  with  it,  when, 
by  a  slight  sawing  motion,  the  muscle  is  severed  from  its 
attachment  to  the  bone.  Schwartze's  tenotome  is  also  most 
satisfactorily  used  for  this  same  purpose  by  gently  inserting 
it  into  the  tympanum  and  towards  the  tegmen;  the  cutting 
edge  is  then  inclined  forward  until  the  position  of  the  head 
of  the  malleus  is  plainly  ascertained,  when,  with  a  slight  for- 
ward rotation  the  knife  engages  the  tendon  of  the  muscle, 
which  is  then  severed,  as  before  directed.  As  the  tendon 
is  cut  through,  one  can  readily  feel  the  consequent  lack  of 
resistance  and  if  the  parts  are  illuminated  as  they  should 
be,  the  manubrium  will  be  seen  to  move  in  an  outward  direc- 


ii2  Suppuration  of  the  Middle  Ear. 

tion.  At  one  time  tenotomy  of  the  tendon  of  the  tensor 
tympani  muscle  was  recommended  as  an  independent  pro- 
cedure in  the  treatment  of  chronic  otorrhcea,  as  it  was  sup- 
posed to  aid  drainage  and  have  some  beneficial  effect  upon 
the  hearing,  and  while  it  may  be  done  when  evidences  of 
caries  of  the  ossicles  are  absent  with  the  perforation  situated 
in  the  lower  segment  of  the  membrana  tympani,  yet  it  is 
absolutely  useless  and  should  only  be  performed  as  one  of 
the  initial  steps  in  removing  the  ossicles.  In  those  cases 
where  the  perforation  is  around  the  manubrium  or  situated 
still  higher  up,  with  caries  of  one  or  both  of  the  ossicles,  this 
procedure,  if  performed  with  the  idea  of  helping  the  patient, 
is  valueless,  as  such  cases  only  can  be  relieved  by  removing 
the  remnants  of  the  tympanic  membrane  and  excising  the 
malleus  and  incus. 

Where  there  is  much  destruction  of  tissue  and  the  malleo- 
incudal  articulation  has  been  opened  the  prominent  short 
process  may  or  may  not  be  seen.  The  parts  are  then  exam- 
ined for  the  somewhat  frequent  adhesion  of  the  manubrium 
to  the  promontory,  and  if  this  is  not  found  but  the  ossicle  be 
free,  it  is  grasped  with  forceps,  preferably  just  below  the 
short  process,  and  readily  extracted  ( see  plate  XIV).  When, 
however,  adhesions  exist,  it  is  best  to  pass  an  angular  knife 
from  above  downwards  along  the  internal  surface  of  the 
manubrium  and  cut  any  bands  which  may  tie  the  bone  down 
in  this  location,  or  if  the  adhesions  are  firm  and  the  malleus 
seems  almost  immovable,  one  should  carefully  avoid  using 
any  force  and  the  adhesions  connecting  the  bone  to  the 
promontory  should  be  divided  with  a  small  knife  curved  on 
the  flat  which  will  then  usually  release  the  bonelet,  but  should 
it  still  remain  fixed,  one  should  cautiously  endeavor  to  find 
the  cause  of  its  binding  down  with  a  fine  probe,  and  when 
the  adhesions  are  located,  a  suitable  knife  should  be  used  to 
divide  them.  In  other  cases,  when  the  major  part  of  the 


The  Treatment  of  the  Ossicles.  113 

membrana  tympani  has  been  destroyed,  but  the  incudo- 
stapedial  articulation  remains  intact,  this  may  be  first  sev- 
ered and  the  malleus  then  removed,  but  this  is  rarely  neces- 
sary. When  the  manubrium  is  carious  or  has  became  rare- 
fied, it  is  very  apt  to  break  as  soon  as  grasped  by  the  forceps 
in  attempting  to  withdraw  the  malleus,  so  it  is  always 
advisable  to  grasp  the  ossicle  higher  up,  and  drawing  it 
slightly  inward,  so  as  to  release  its  neck  from  its  insertion 
into  the  notch  of  Rivinius,  it  is  then  brought  downward 
and  easily  extracted  from  the  canal;  various  forceps  may 
be  used  for  this  purpose,  as  alligator  forceps,  Sexton's,  Hart- 
mann's,  etc.  Again,  gentle  traction  or  a  slight  rotary  mo- 
tion of  the  ossicle  grasped  in  the  forceps  from  side  to  side 
may  be  made,  until  it  is  thus  brought  into  the  lower  part  of 
the  tympanic  cavity  on  a  level  with  the  canal,  when  it  is 
turned  to  one  side  and  so  extracted.  In  some  cases,  where 
the  malleus  presents  but  little  apparent  alteration,  its  connec- 
tion with  the  margin  of  bone  above  should  not  be  interfered 
with  until  it  has  been  entirely  separated  from  its  natural 
attachments  and  the  incudo-stapedial  articulation  has  been 
severed,  so  that  the  manubrium  retains  its  natural  position 
and  does  not  move  out  of  place. 

It  frequently  occurs  that  the  destruction  has  been  so  great 
that  a  greater  portion  of  the  incus  is  necrotic  and  has  become 
entirely  detached  from  the  malleus.  Under  these  conditions 
the  removing  of  the  latter  bonelet  is  very  simple,  as  it  only 
is  necessary  to  grasp  with  forceps  and  lift  it  out  of  the 
tympanic  cavity  where  it  lies  practically  as  a  foreign  body, 
being  free  from  its  membranous  attachments.  When  this 
ossicle  is  firmly  attached  superiorly  to  the  margo  tympanicus 
and  Rivinian  segment,  several  semicircular  incisions  in  this 
region  with  a  straight-pointed  knife  will  usually  suffice  to 
loosen  it  and  it  may  be  removed  with  the  loop  of  a  snare  or 
seized  by  forceps  at  its  neck  and  then  drawn  down  until  it 

9 


ii4  '  Suppuration  of  the  Middle  Ear. 

can  be  extracted.  When  adhesions  firmly  hold  the  malleus 
to  the  incus,  great  difficulty  may  be  experienced  in  its  ex- 
traction, as  this  may  be  composed  of  a  purely  connective 
tissue  growth,  or  the  union  between  the  two  ossicles  may  con- 
sist of  a  true  ankylosis  and  in  such  cases  when  the  manu- 
brium  is  caught  in  the  forceps  it  is  very  apt  to  break  off 
and  the  body  of  the  malleus  remains  attached  to  the  incus 
in  the  epitympanum.  The  breaking  of  the  bonelet  in  this 
manner  is  due  primarily  to  the  weakening  of  its  structure 
from  absorption  of  osseous  tissue  or  the  using  of  too  much 
force  in  its  extraction. 

Another  method  of  removing  the  malleus,  which  is  appli- 
cable when  the  bone  is  freely  exposed,  is  by  the  use  of  an 
oval  ring  knife  of  which  several  varieties  may  be  obtained, 
that  of  Delstanche  being  quite  satisfactory.  The  ring  with 
the  blade  is  placed  at  an  angle  to  the  handle,  so  that  the  cut- 
ting edge  is  directed  upwards  and  by  placing  this  around 
the  malleus  it  is  pushed  from  below  upwards  so  that  it 
severs  the  tendon  of  the  tensor  tympani  muscle,  and  then,  by 
gently  rotating  it  outwards,  the  malleus  is  so  brought  down 
that  it  can  be  removed  with  forceps.  As  a  final  method  of 
removing  the  malleus  that  described  by  Dench  is  extremely 
satisfactory :  "  The  stapes  tendon  is  first  divided,  then  the 
incudo-stapedial  articulation  is  severed  and  with  a  pointed 
knife  Shrapnell's  membrane  and  the  ligaments  binding  the 
malleus  anteriorly  and  posteriorly  are  severed,  the  knife  is 
then  held  so  that  the  flat  surface  of  the  blade  is  directed 
towards  the  roof  of  the  canal  and  the  edge  backwards,  so 
that  the  point,  entering  just  above  the  short  process  of  the 
malleus,  is  pushed  inward  and  upward  and  the  handle  is 
depressed.  In  this  way  the  knife  enters  the  fornix  of  the 
tympanum  and  cuts  its  way  outwards,  downwards  and  back- 
wards, thus  severing  the  external  and  posterior  ligaments  of 
the  malleus  and  dividing  Shrapnell's  membrane  posteriorly. 


EXPLANATORY    NOTE    TO    PLATE    XV. 


A  schematic  drawing  demonstrating  the  removal  of  the  incus,  after  the  com- 
pletion of  the  removal  of  the  malleus.  An  angular  knife  in  position  cutting  through 
the  suspensory  ligament  of  the  incus. 


116 


PLATE  XV 


The  Treatment  of  the  Ossicles.  117 

The  knife  is  then  reversed  and  cuts  in  the  opposite  direc- 
tion, is  carried  forward  over  the  short  process  and  divides 
the  anterior  segment  of  the  membrane,  some  fibers  of  the 
external  ligament  and  the  anterior  ligament  of  the  malleus. 
As  the  bonelet  is  now  only  held  in  place  by  the  weak  supe- 
rior ligament  and  the  tendon  of  the  tensor  tympani  muscle, 
it  is  grasped  with  suitable  forceps  just  below  the  short  process 
and  extracted  by  pressing  inwards  to  dislodge  the  neck  of 
the  bone  from  the  projection  upon  which  it  rests,  and  this 
is  followed  by  traction  downwards,  then  outwards" (Dench). 
Following  the  removal  of  the  malleus,  the  next  step  in  the 
operation  should  be  the  extraction  of  the  incus,  as  it  is  more 
frequently  involved  in  the  carious  process  than  any  other 
ossicle.  Schroeder  in  one  hundred  and  thirty  operations  of 
this  nature,  which  he  considers  as  the  only  sure  means  of 
benefiting  attical  suppuration  and  which  he  states  should 
always  precede  any  form  of  radical  operation  on  the  mas- 
toid,  found  caries  of  the  incus  in  88  per  cent,  of  his  cases, 
while  in  41  per  cent,  of  these  the  malleus  was  found  to  be 
normal,  and  for  this  reason  it  is  highly  important  that  the 
incus  should  be  removed  after  extracting  the  malleus.  Lude- 
wig  found  it  carious  in  85  per  cent. ;  in  twenty-nine  cases  of 
Bench's  it  was  carious  in  nineteen,  while  in  eight  of  these  it 
was  completely  destroyed.  This  peculiar  susceptibility  of 
the  incus  to  be  involved  to  such  an  extent  in  the  carious 
process  is  readily  seen  by  an  examination  of  its  blood  supply 
and  topographical  relations,  as  the  vascular  supply  is  ex- 
tremely limited,  being  derived  only  from  the  minute  petrosal 
branch  of  the  stylo-mastoid  artery,  which  from  its  super- 
ficial position  in  the  upper  tympanic  space  is  easily  com- 
pressed by  any  swelling  of  the  mucous  membrane  which  takes 
place  in  this  region,  it  being  the  rule  that  when  the  ossicular 
chain  is  involved  in  the  carious  process  the  incus  is  affected 
not  only  first  but  also  to  the  greatest  extent.  On  account 


ii8  Suppuration  of  the  Middle  Ear. 

of  its  position  and  the  delicacy  of  its  supporting  ligaments, 
the  suppurative  process  in  the  epitympanum  from  an  early 
stage  directly  involves  this  bonelet,  its  peculiar  shape  espe- 
cially predisposing  it  to  the  full  destructive  action  of  the 
purulent  secretions.  Undoubtedly  its  scanty  vascular  sup- 
ply is  by  far  the  main  feature  concerned  in  this  process,  but 
at  the  same  time  the  other  factors  mentioned  play  an  impor- 
tant role  as  contributing  causes.  The  most  common  spot 
on  the  ossicle  which  seems  to  apparently  be  primarily  in- 
volved by  the  caries  is  its  long  process  near  the  body,  or 
the  body  itself  may  be  in  great  part  destroyed,  so  that  its 
posterior  portions  remain  intact  and  its  partially  carious 
long  process  articulate  to  the  stapes ;  the  frequency  in  which 
this  joint  becomes  involved  being  illustrated  by  Green's  cases, 
in  which  this  took  place  in  75  per  cent. 

Should  the  incudo-stapedial  joint,  however,  still  remain 
intact,  it  must  first  be  severed  before  the  incus  can  be  re- 
moved. This  may  be  done  by  the  use  of  a  small  sharp- 
pointed  knife  placed  at  nearly  a  right  angle  with  the  shaft 
and  an  incision  is  made  through  the  articulation  as  near  as 
possible,  perpendicular  to  the  axis  of  the  stapes.  As  soon 
as  the  joint  has  been  divided  the  added  movement  given  to 
the  long  process  of  the  incus  will  indicate  that  this  measure 
has  been  successful  in  those  cases  where  the  incus  is  placed 
high  up  on  the  wall  of  the  tympanum,  while  where  it  is 
situated  more  inferiorly,  the  entire  procedure  can  be  readily 
seen.  The  articulation  may  also  be  severed  by  placing  the 
knife  behind  the  long  process  of  the  incus  and  by  cutting 
forward  and  downward  the  action  is  more  or  less  resisted 
by  the  stapedius  muscle,  and  any  damage  to  the  stapes  is 
in  this  way  reduced  to  a  minimum  and  the  division  of  the 
articulation  is  more  easily  performed.  The  long  arm  of  the 
incus  should  be  used  as  the  main  landmark  in  performing 
this  part  of  the  operation  and  after  the  joint  has  been  sev- 


The  Treatment  of  the  Ossicles.  119 

ered  by  any  of  the  various  methods  here  described  it  is 
always  advisable  to  insert  the  point  of  the  knife  below  and 
draw  it  upwards,  to  sever  any  undivided  ligaments  of  the 
capsule  that  may  still  remain;  the  knife  may  also  for  this 
purpose  be  drawn  as  far  as  possible  around  the  long  process 
of  the  incus,  at  the  same  time  cutting  downwards.  Many 
operators  consider  it  advisable  to  cut  the  tendon  of  the  sta- 
pedius  muscle  before  attacking  this  articulation,  as  it  is 
claimed  by  this  procedure  that  the  parts  can  be  more  per- 
fectly seen;  the  method  of  doing  this  therefore  will  be  con- 
sidered later  in  connection  with  the  operative  procedures 
upon  the  stapes.  When  it  is  difficult  to  insert  the  knife 
between  the  annulus  tympanicus  and  the  long  process  of 
the  incus  to  sever  this  articulation,  the  procedure  recom- 
mended by  Bench  may  be  satisfactorily  adopted  by  passing 
the  cutting  instrument  in  front  of  the  long  arm  of  the  incus 
and  open  the  articulation  by  cutting  downwards  and  back- 
wards, as  it  may  be  severed  from  its  lower  aspect  by  cutting 
through  it  backwards  and  forwards. 

After  this  articulation  has  been  severed,  the  incus  may 
be  removed  by  any  one  of  several  methods,  depending 
whether  it  has  remained  in  its  usual  situation  or  has  altered 
its  position.  A  few  otologists  remove  the  incus  previous 
to  excising  the  malleus  on  account  of  the  supposed  danger 
of  the  former  becoming  dislodged  into  the  posterior  inferior 
part  of  the  tympanic  cavity,  where  it  is  extremely  difficult  of 
access.  But  this  method  is  not  to  be  recommended  as  it  is 
generally  impracticable,  and  where  the  suppuration  has  been 
extensive  only  a  small  remnant  of  the  incus  will  be  found 
after  the  malleus  has  been  removed,  the  former  being  dis- 
lodged from  its  position  in  the  attic  and  brought  forwards 
and  downwards  into  the  tympanic  cavity,  when  it  can  be 
removed.  It  should  be  remembered  that  in  a  certain  pro- 
portion of  cases  the  greater  part  of  the  incus  has  been  de- 


120  Suppuration  of  the  Middle  Ear. 

stroyed,  and  what  remains  of  its  body  is  fused  to  the  malleus, 
so  that  when  the  latter  is  removed  the  incus  is  carried  away 
with  it,  a  careful  examination  of  the  former  being  always 
advisable  before  search  is  made  for  a  supposedly  missing 
incus.  While  the.  extraction  of  the  incus  is  much  more 
difficult  than  the  removal  of  the  malleus,  yet  in  practically 
all  cases  both  the  ossicles  should  be  removed  inasmuch  as 
already  shown  the  former  being  more  frequently  carious, 
if  allowed  to  remain  keeps  up  the  suppurative  process.  As 
a  further  necessity  for  removing  the  incus,  its  function  is 
of  course  lost  when  the  hammer  has  been  removed  and  it 
is  most  advisable  under  all  circumstances  to  remove  it  or  its 
necrosed  remnants  with  the  various  hooks  used  for  this  pur- 
pose. In  some  cases  the  procedures  mentioned  will  allow 
the  incus  or  at  least  its  long  process  to  be  seen  and  then  by 
drawing  it  downward,  forward  and  outward  no  difficulty  at 
all  is  encountered  in  its  removal;  on  the  other  hand,  it  is 
often  displaced  downward  and  is  closely  associated  with  the 
border  of  the  tympanic  ring,  so  that  its  long  process  espe- 
cially appears  to  be  a  part  of  the  annulus  and  in  not  a  few 
instances  one  will  have  to  carefully  differentiate  one  bony 
process  from  the  other  by  using  the  probe,  so  that  when  the 
incus  is  recognized  it  can  most  usually  be  lifted  away  with 
the  forceps,  or  more  rarely  it  will  have  to  be  slightly  moved 
from  this  position  before  it  can  be  securely  grasped  by  the 
forceps  or  a  right-angle  blunt  spoon  with  its  concavity  di- 
rected backwards,  which  is  very  useful  for  this  particular 
purpose. 

In  a  considerable  number  of  cases  of  chronic  otorrhcea, 
after  one  has  removed  the  malleus,  no  trace  can  be  seen  of 
the  incus,  and  it  then  becomes  necessary  to  carefully  search 
for  it  until  it  has  been  found,  or  positive  evidence  is  ob- 
tained that  it  is  not  present.  In  such  cases  various  methods 
may  be  employed  to  remove  the  remnants  of  this  ossicle  de- 


EXPLANATORY    NOTE    TO    PLATE    XVI. 


A  schematic  side  view  of  the  tympanum  showing  necrosis  of  the  handle  of  the 
malleus  and  a  polypus  protruding  through  the  drum  membrane. 

i,  Polypoid  excrescence;  2,  drum  membrane;  3,  necrosis  of  the  handle  of  the 
malleus ;  4,  external  auditory  canal. 


122 


PLATE  XVI 


The  Treatment  of  the  Ossicles.  123 

pending  upon  its  supposed  location,  various  forms  of  incus 
hooks  being  used  to  bring  its  long  process  into  view.  These 
hooks  are  curved  so  that  one  is  available  for  the  right,  the 
other  for  the  left  ear,  and  in  using  them  one  should  guard 
against  the  hook  catching  in  the  process  of  bone  over  the 
antral  entrance  in  endeavoring  to  search  for  this  ossicle,  as 
this  accident  is  apt  to  happen  if  the  hook  be  made  too  long. 
The  incus  hook  for  the  side  to  be  operated  on  is  pushed  into 
the  cavum  tympani  and  its  angular  portion  is  inserted  well 
behind  the  tympanic  ring  in  the  position  of  the  missing  incus, 
when  it  is  slightly  rotated  forward  and  at  the  same  time 
carried  upward,  so  that  it  will  swing  the  long  arm  of  the 
bone  into  the  field  of  vision.  Alderton  for  this  purpose  uses 
Ludewig's  incus  hooks,  or  a  right-angle  spoon  carried  up  in 
a  vertical  position  behind  the  pars  epitympanica  and  as  far 
forwards  as  possible  until  the  shank  touches  the  bone;  it  is 
then  carried  backwards,  maintaining  it  close  to  the  inner 
surface  of  the  pars  until  it  occupies  the  normal  situation  of 
the  incus,  when  the  tip  is  rotated  backwards  towards  the 
aditus  until  the  incus  is  engaged,  when  it  is  brought  into 
view  by  traction  downwards.  If  these  procedures  should 
fail  as  a  result  of  the  incus  lying  in  a  lower  position,  or  is 
in  part  in  very  close  contact  with  the  tympanic  ring,  one  may 
adopt  the  procedure  used  by  Bench  of  entering  the  hook 
at  the  antero-inf  erior  portion  of  the  tympanum  with  its  con- 
cavity directed  posteriorly,  and  by  rotating  and  sweeping 
backwards  and  upwards  the  extremity  which  touches  the 
tympanic  ring,  the  incus  will  be  brought  into  view  if  it  is 
in  the  antero-inferior  part  of  the  tympanum.  If  it  should 
not  be  found  here,  however,  the  hook  should  be  directed 
upwards  and  forwards  through  the  posterior  and  superior 
parts  of  the  tympanic  cavity,  and  at  the  same  time  keeping 
it  pressed  firmly  against  the  internal  margin  of  the  tym- 
panic ring.  Care  should  be  exercised  in  performing  this 


124  Suppuration  of  the  Middle  Ear. 

manoeuvre  that  the  stapes  is  not  damaged.  Should  this  not 
bring  the  incus  into  view,  use  the  hook  designed  for  the  oppo- 
site ear  and  carry  it  into  the  fornix  tympani  with  the  con- 
cavity directed  backwards  and  its  angular  portion  hooked 
behind  the  inner  extremity  of  the  superior  wall  of  the  exter- 
nal auditory  canal,  when  it  is  rotated  backwards  and  carried 
downwards  and  usually  this  procedure  will  bring  the  bonelet 
into  view  where  its  posterior  ligament  is  unduly  strong  or  its 
long  process  has  rotated  too  far  backwards  out  of  reach 
of  the  hook.  This  method  should,  however,  only  be  used  as 
a  last  resort,  as,  if  used  at  first,  it  is  very  apt  to  displace  the 
incus  into  the  antrum,  where  it  is  impossible  to  recover  it 
by  way  of  the  canal.  Kretchmann,  in  removing  this  ossicle, 
uses  a  curved  hook  which  is  so  bent  at  its  distal  extremity 
that  its  tip  will  rest  on  the  osseous  shelf  of  the  superior  wall 
of  the  canal  which  affords  a  lodgment  for  the  incus.  By 
this  method  the  hook  is  introduced  with  its  concavity  back- 
wards and  brings  the  incus  into  view  by  rotation  backwards 
with  moderate  traction  downwards,  the  objectional  feature 
of  this  method,  however,  being  that  one  is  very  apt  to  dis- 
place the  bonelet  into  the  antrum,  although  the  danger  of 
doing  this  may  be  avoided  to  some  extent  by  entering  the 
hook  posterior  to  the  long  process  providing  such  be  visible 
and  rotating  it  forwards.  In  a  few  cases,  where  the  incus 
is  not  seen,  it  may  in  great  part  be  covered  by  the  membrane 
which  has  not  been  incised  close  enough  to  the  tympanic 
ring,  or  the  destruction  of  the  osseous  part  of  the  annulus 
at  this  point  may  render  its  recognition  almost  impossible, 
especially  if  the  incus  be  adherent  to  these  parts.  Under 
these  conditions  it  is  necessary  to  remove  the  soft  parts  to 
ascertain  if  it  be  present,  and  if  it  be  not  found,  even  after 
performing  the  various  procedures  previously  indicated,  one 
may  be  fairly  sure  that  it  has  either  been  pushed  back  into 
the  antrum  or  destroyed  by  the  suppurative  process. 


The  Treatment  of  the  Ossicles.  125 

When  only  a  portion  of  the  incus  remains  and  this  is 
usually  its  body  which  is  frequently  calcified  and  adherent 
to  adjacent  tissues,  Ludewig's  hooks  are  more  satisfactory 
for  its  removal  than  any  other  form  of  instrument.  With 
such  a  condition  present,  the  hook  is  directed  towards  the 
antero-superior  part  of  the  attic  and  with  its  concave  sur- 
face directed  backwards  it  is  moved  in  a  posterior  direction 
so  as  to  engage  the  remnants  of  this  ossicle.  When  the  attic 
seems  to  be  unusually  capacious,  this  procedure  should  be 
repeated  several  times,  so  that  the  entire  attical  space  is  ex- 
plored and  the  incus  engaged,  but  great  care  should  be  exer- 
cised when  passing  the  instrument  along  the  median  wall  to 
avoid  the  facial  canal,  as  the  nerve  is  undoubtedly  in  danger 
at  this  point  (see  plate  I).  If  this  procedure  should  prove 
to  be  futile,  however,  it  may  in  some  cases  be  reversed  with 
successful  results,  the  incus  hook  being  swept  from  behind 
forwards  and  thus  removing  the  ossicle  in  this  manner. 
Ludewig's  method  of  removal  of  the  incus,  necessitates  the 
preliminary  excision  of  the  malleus  and  the  severing  of  the 
incudo-stapedial  articulation.  The  incus  hook  is  introduced 
into  the  upper  tympanic  space  beneath  the  segment  of  Rivin- 
ius  and  its  point  is  turned  upwards ;  the  hook  is  then  turned 
backwards  and  rotated  in  a  semi-circular  manner  down- 
wards, so  that  the  point  of  the  hook  grasps  the  incus  at  its 
saddle-shaped  facet  and  dislodges  it  into  the  lower  tympanic 
space,  where  it  is  removed  either  by  syringing  or  preferably 
by  forceps.  The  method  advocated  by  Zeroni  may  finally 
be  mentioned  in  this  connection,  although  it  is  not  as  suc- 
cessful in  its  application  as  some  of  the  other  methods  here 
described.  Instead  of  the  usual  incus  hook,  an  eyelet  is 
employed  by  introducing  it  into  the  posterior  part  of  the 
tympanic  cavity  and  carrying  it  along  the  medial  wall  from 
below  upwards,  it  is  slightly  drawn  towards  the  external  attic 
wall  and  grasps  the  incus  when  the  latter  is  drawn  into  view 
by  a  slight  downward  pull. 


i26  Suppuration  of  the  Middle  Ear. 

Various  untoward  symptoms  or  accidents  are  liable  to 
take  place  during  attempted  removal  of  this  ossicle,  such 
as  pain  in  the  head,  vomiting  and  vertigo,  the  latter  being 
especially  frequent  when  the  patient  is  conscious  and  local 
anaesthesia  alone  is  being  used;  however,  these  symptoms 
are  usually  of  but  transient  duration,  with  the  exception  of 
the  vertigo,  which  may  last  for  several  weeks  before  it  per- 
manently disappears.  Hemorrhage,  as  previously  noted, 
can  usually  be  controlled  without  any  serious  difficulty,  but 
rarely  it  may  be  quite  profuse  and  seriously  compromise  the 
operation,  a  case  in  this  relation  being  recorded  by  Ludewig 
in  which  the  bulb  of  the  jugular  vein  was  injured  through  a 
cleft  in  the  inferior  wall  of  the  tympanic  cavity.  The  incus 
hook,  if  used  too  forcibly,  or  if  the  Fallopian  canal  be  defi- 
cient in  this  region,  may  produce  a  temporary  facial  paral- 
ysis from  injury  to  the  nerve,  and  while  this  accident  is  rare, 
yet  it  is  always  advisable  to  have  an  assistant  watch  the 
patient's  face  for  twitching  of  the  muscles  during  any  oper- 
ative manipulations  in  this  portion  of  the  tympanic  cavity. 
Finally  accidents  may  take  place  in  regard  to  the  incus  itself, 
as  it  may  become  impacted  in  the  posterior  part  of  the  tym- 
panum and  will  be  extracted  with  more  or  less  difficulty  by 
means  of  the  various  procedures  which  have  been  previously 
described;  or,  what  is  much  more  serious,  careless  manipu- 
lation may  dislocate  it  backwards  into  the  antrum,  when  a 
mastoid  operation  will  be  necessary  for  its  extraction. 

Before  considering  the  question  of  the  advisability  of 
removing  the  stapes  in  chronic  suppuration  of  the  tympanic 
cavity,  the  method  of  cutting  the  tendon  of  the  stapedius 
muscle  will  demand  some  consideration,  and  as  before  men- 
tioned, this  procedure  is  often  performed  as  an  initial  step 
in  removing  the  ossicular  chain,  as  it  brings  the  incudo- 
stapedial  articulation  more  into  the  line  of  vision.  The  pro- 
cedure requires  but  little  description,  as  it  is  readily  per- 


The  Treatment  of  the  Ossicles.  127 

formed  by  inserting  a  straight  knife  above  and  behind  the 
head  of  the  stapes  and  between  it  and  the  tympanic  ring;  it 
is  then  directed  inwards  until  its  point  lightly  touches  the 
inner  tympanic  wall,  when  it  is  slightly  withdrawn  and  the 
tendon  is  severed  in  a  direction  downward. 

While  but  few  otologists  claim  that  the  removal  of  the 
stapes  is  either  necessary  or  free  from  danger  in  suppura- 
tive  conditions  of  the  tympanum,  the  greater  number  exer- 
cise a  more  conservative  feeling  in  this  respect,  and  advise 
not  only  that  this  ossicle  should  be  removed,  but  that  in  the 
presence  of  pus  in  its  locality,  it  should  be  avoided  in  every 
way  and  should  not  even  be  mobilized  for  fear  of  the  infec- 
tion passing  through  the  oval  window  and  producing  serious, 
if  not  fatal,  change  to  the  labyrinth  and  intracranial  struc- 
tures. Undoubtedly,  the  latter  position  is  not  only  safe  and 
eminently  surgical,  but  is  also  expressive  of  the  best  interests 
of  the  patient,  the  author  not  being  of  the  opinion  of  those 
who  remove  the  stapes,  even  if  it  is  found  somewhat  carious, 
although  the  position  of  Grunert  may  be  well  taken  that  the 
removal  of  this  ossicle  is  not  necessarily  followed  by  injury 
to  the  hearing,  nor  an  intracranial  lesion.  The  method  of 
removing  the  stapes  presents  but  little  difficulty  when  the 
malleus  and  incus  have  been  removed  and  the  stapedius  ten- 
don severed,  as  with  a  straight  knife  it  is  freed  from  its 
attachment  to  the  notch  of  the  oval  window,  and  with  a  sharp 
or  blunt  hook  placed  between  its  crura  it  is  removed  by 
carefully  drawing  it  out.  That  the  removal  of  the  stapes 
in  the  presence  of  a  suppurative  process  in  this  region  is 
extremely  hazardous,  is  well  shown  by  a  case  reported  by 
Politzer,  in  which  this  ossicle  was  accidentally  removed 
during  the  performance  of  a  radical  operation  and  was  fol- 
lowed by  the  death  of  the  patient.  Sections  of  the  parts 
showed  a  granulation  tissue  mass  filling  the  niche  of  the 
oval  window  and  passing  through  the  labyrinth  window  into 


128  Suppuration  of  the  Middle  Ear. 

the  vestibule,  where  it  filled  the  whole  of  the  cisterna  peri- 
lymphatica.  The  utriculus  showed  inflammatory  thicken- 
ing, horizontal  semicircular  canal  was  filled  with  a  con- 
nective tissue  network  between  the  membraneous  and  osseous 
canals,  and  was  filled  with  round  cells  and  dilated  blood- 
vessels, while  the  cochlea  was  also  seriously  compromised  by 
the  inflammatory  changes. 

Another  method  of  removing  the  ossicles  and  curetting 
the  morbid  tissue  from  the  attic  is  that  of  Vasher.  This  is 
performed  under  general  anaesthesia  by  detaching  the  upper 
half  of  the  membraneous  canal  by  an  anterior  and  posterior 
incision  through  the  soft  tissues  from  the  tympanic  cavity 
to  the  auricle,  the  incisions  being  made  from  within  out- 
wards. The  superior  half  of  the  canal  is  then  separated 
from  the  osseous  tissue  with  an  elevator  or  blunt  spatula 
and  pulled  outwards,  the  periosteum  and  osseous  tissue  above 
is  then  scraped  away,  so  that  a  large  part  of  the  osseous 
entrance  of  the  canal  is  exposed  to  view.  In  order  to  obtain 
a  large  cavity  it  is  also  suggested  that  the  entire  upper  wall 
of  the  canal  be  removed  and  also  a  part  of  the  outer  wall,  so 
that  the  ossicles  may  readily  be  removed  and  the  attic  thor- 
oughly curetted.  After  removing  the  diseased  tissue  in  this 
way  the  incised  portions  of  the  canal  are  again  placed  in 
position  and  firmly  retained  in  place  by  a  narrow  strip  of 
gauze  placed  against  the  upper  external  wall  of  the  canal 
to  avoid  any  tendency  towards  atresia  which  may  occur.  In 
those  cases  where  the  tissue  flap  has  been  in  great  part 
destroyed  by  its  removal  it  is  necessary  to  entirely  excise 
it  and  allow  the  parts  to  heal  by  granulation.  Practically 
this  operation  aims  to  accomplish  the  same  results  as  a 
Stacke  without,  however,  detaching  the  auricle,  but  it  must 
of  necessity  fall  far  short  of  accomplishing  any  such  results, 
as  in  those  cases  where  the  symptoms  point  to  the  removal 
of  the  ossicles  through  the  canal  by  the  methods  previously 


The  Treatment  of  the  Ossicles.  129 

mentioned,  such  an  operation  as  this  presents  no  advantages 
at  all  and  many  disadvantages,  while  in  the  class  of  cases 
in  which  the  carious  process  is  more  extensive,  a  Stacke  or 
even  more  radical  operation  is  absolutely  indicated,  as  by 
the  Vacher  method  all  the  diseased  tissue  cannot  be  removed, 
and  at  the  same  time  the  danger  of  serious  stenosis  of  the 
auditory  canal  is  greatly  enhanced. 

In  all  the  operations  here  described  for  removing  the 
malleus  and  incus,  the  chorda  tympani  nerve  as  it  passes  in 
intimate  relation  with  these  ossicles  is  practically  always 
destroyed,  but  this  is  of  little  moment,  as  the  most  serious 
result  from  this  is  a  partial  loss  of  taste  and  in  practically 
every  case  the  alteration  lasts  but  a  few  weeks  at  the  most. 
While  this  is  a  more  or  less  essential  incident  to  this  opera- 
tion, yet  more  serious  accidents  are  sometimes  apparently 
unavoidable,  the  majority  of  which  have  already  been  pointed 
out,  but  it  is  further  desired  to  mention  here  that  the  facial 
nerve  may  be  damaged,  so  that  facial  palsy  or  paralysis  will 
ensue;  however,  such  an  untoward  event  during  an  ossicu- 
lectomy  is  not  common,  and  as  usually  happens,  the  result- 
ant paralysis  is  amenable  to  treatment.  Marked  impair- 
ment of  hearing  is  a  most  unfortunate  accident  that  may 
result  from  damage  to  the  stapes  by  its  impaction  in  the 
oval  window,  or  still  more  serious  consequences  may  ensue 
from  labyrinthine  injury,  the  result  of  accidental  removal  of 
this  ossicle  either  as  the  result  of  traumatism  during  the 
course  of  the  operation,  or  by  the  extension  of  the  purulent 
inflammation  through  the  exposed  oval  window,  to  the  inter- 
nal ear.  As  regards  the  hearing,  however,  being  altered  in 
any  respect  as  the  result  of  the  ossiculectomy,  but  little  evi- 
dence can  be  offered  on  this  point,  as  the  primary  and  sole 
object  of  the  operation  is  to  prevent  the  further  extension 
of  the  purulent  inflammation,  or  to  cure  the  otorrhcea,  and 
the  question  of  hearing,  while  of  great  importance,  yet  must 


130  Suppuration  of  the  Middle  Ear. 

be  of  secondary  consideration.  When  the  suppurative  otitis 
is  associated  with  impairment  of  hearing,  the  result  of  the 
excessive  secretion  and  morbid  tissue  filling  the  tympanic 
cavity,  so  that  the  ossicles  are  rigid  and  sound  waves  are  pre- 
vented from  being  transmitted  to  the  inner  ear,  then  one  can 
expect  a  marked  improvement  in  the  auditory  acuity  as  the 
result  of  the  now  valueless  malleus  and  incus  being  removed, 
by  allowing  the  sound  waves  to  reach  the  stapes  and  inner 
tympanic  wall  without  obstruction.  One  can  never  judge, 
however,  by  the  impairment  of  hearing  the  extent  of  the 
morbid  process  in  the  tympanic  cavity,  but  as  a  rule  when 
the  patient  seriously  places  the  results  of  the  operation  as 
regards  his  hearing  foremost,  it  is  well  to  avoid  ossiculec- 
tomy  if  such  be  possible  in  those  cases  where  the  hearing  is 
near  the  normal;  for  while  in  the  larger  number  it  remains 
uninfluenced  or  even  slightly  improved,  yet  in  the  smaller 
number  it  is  apt  to  become  very  much  impaired. 

The  final  results  in  ossiculectomy,  as  regards  the  cure 
or  amelioration  of  the  chronic  suppuration,  are  usually  most 
satisfactory  when  the  accessory  cavities  or  walls  of  the  tym- 
panum are  not  too  extensively  involved,  Kretschmann  in 
thirteen  cases  cured  eight ;  Stucky  in  twenty-nine  had  twenty- 
four  cures;  Alderton  in  twenty-two  consecutive  cases  had 
fifteen  cures  and  four  cases  which  improved,  while  Grunert 
had  thirteen  cures  in  twenty-eight  cases;  Dench  fifteen  in 
twenty-nine;  Ludewig  forty-two  cures  in  seventy-five  opera- 
tions, and  the  author  had  twenty-three  cures  in  sixty-eight 
operations.  By  removing  the  ossicles,  not  only  is  the  dis- 
eased tissue  removed  and  the  drainage  improved,  which  in 
itself  tends  towards  the  restoration  of  the  parts,  but  the 
suppurative  process  is  in  the  majority  of  cases  prevented 
from  extending  to  more  dangerous  areas  and  even  when  the 
tympanic  walls  are  involved  to  some  degree,  recovery  may 
ensue  as  these  parts  are  thus  placed  in  a  position  where  they 


The  Treatment  of  the  Ossicles.  131 

can  be  directly  treated.  In  some  cases  the  suppuration 
ceases  within  a  few  days  or  weeks  after  the  operation,  and 
but  little  after  treatment  is  required,  while  in  others  it  may 
require  a  number  of  months  before  this  desirable  result  is 
obtained,  or  although  the  suppuration  may  be  lessened  by 
the  ossiculectomy,  yet  its  prolonged  continuance  will  suggest 
the  presence  of  carious  bone  still  remaining  and  radical  oper- 
ation will  be  required.  In  all  such  cases,  however,  where 
the  suppuration  continues  for  a  number  of  months  after 
removal  of  the  ossicles,  it  is  well,  as  pointed  out  by  Grunert 
and  Zeroni,  to  delay  the  radical  operation  for  a  considerable 
time,  as  the  suppuration  may  finally  cease  as  the  result  of 
continued  after  treatment. 


CHAPTER  V. 

THE  TREATMENT   OF   CARIES   OF  THE 

TYMPANIC    WALLS,    THE    EPITYM- 

PANUM  AND  HYPOTYMPANUM. 


133 


THE  TREATMENT  OF   CARIES  OF  THE   TYMPANIC  WALLS, 
THE    EPITYMPANUM   AND    HYPOTYMPANUM. 

Inasmuch  as  carious  processes  involving  the  walls  of  the 
tympanic  cavity  do  not,  as  a  rule,  occur  alone,  but  are  always 
intimately  associated  with  morbid  changes  of  the  mucous 
membrane  and  frequently,  but  to  a  less  degree,  with  caries 
or  necrosis  of  the  malleus  and  incus,  it  is  evident  that  the 
pathological  products,  acting  both  as  a  cause  of  necrosis  and 
caries  and  resulting  in  great  part  from  these  changes,  have 
to  some  extent  been  described  in  the  preceding  chapters.  It 
is  desired  here,  however,  to  more  intimately  describe  the  sur- 
gical treatment  of  the  carious  changes  in  the  tympanic  walls 
and  adjacent  regions  accessible  through  the  external  canal, 
either  in  those  cases  where  it  is  not  necessary  to  remove  the 
ossicles  on  account  of  the  bone  disease  being  limited  in  area 
and  easily  accessible,  or  in  the  much  larger  class  where  the 
ossicles  are  involved  and  the  molecular  changes  in  the  attic 
or  lower  tympanic  walls  are  in  intimate  association  with  the 
presence  of  polypi,  granulation  tissue  or  cholesteatomatous 
masses,  the  latter  especially  being  always  indicative  of  a  sup- 
purative  process  of  such  duration  that  the  coincident  pres- 

135 


136  Suppuration  of  the  Middle  Ear. 

ence  of  osseous  lesions  may  generally  be  presupposed.  The 
recognition  of  a  carious  area  involving  the  walls  of  the  tym- 
panic cavity  is  usually  absolute  should  the  mucosa  in  defi- 
nite regions  become  markedly  altered  in  color,  or  present  a 
pale  yellow-gray  appearance,  and  the  probe,  when  inserted 
through  these  patches,  transmits  a  decided  feeling  of  rough- 
ness to  the  examiner's  hand.  This  appearance,  however, 
is  not  often  so  characteristic  and  in  the  great  majority  of 
patients  with  chronic  otorrhcea  one  cannot  be  certain  as  to 
the  pathological  findings  in  the  osseous  tissue  hidden  beneath 
the  mucoperiosteum  until  the  contents  of  the  tympanum 
have  been  entirely  removed.  In  still  another  group  of  cases, 
although  the  ossicles  are  involved,  there  will  be  no  apparent 
subjective  or  objective  symptoms  indicating  extensive  dis- 
ease of  the  osseous  walls  until  later  radical  operation  reveals 
it  after  the  suppuration  has  continued  in  spite  of  ossiculec- 
tomy  and  treatment  directed  to  the  mucosa. 

While  the  diagnosis  of  this  condition  is  so  often  difficult 
and  at  times  even  impossible,  it  is  usually  located  at  such  a 
position  that  it  is  inaccessible  by  way  of  the  canal,  and 
therefore  treatment  by  this  route  will  prove  futile  in  removing 
the  cause  of  the  continued  suppuration,  even  though  the  ossi- 
cles be  removed  and  the  granulations  and  epithelial  masses 
be  thoroughly  curetted  away.  In  many  cases  the  carious 
area,  although  accessible  through  the  canal,  will  be  entirely 
covered  with  a  mass  of  exuberant  granulation  tissue,  so  that 
its  detection  depends  entirely  upon  the  careful  search  with 
the  blunt  flexible  silver  probe,  especial  care  being  exercised 
in  all  cases  when  probing  the  internal  wall  to  avoid  pene- 
trating into  the  labyrinth  through  a  soft  and  disintegrated 
spot  of  bone  in  this  situation,  and  when  the  disease  is  seem- 
ingly confined  to  the  walls  and  the  ossicles  are  in  situ,  one 
must  always  be  cautious  in  handling  the  probe  in  the  then 
restricted  space  that  the  ossicular  chain  be  not  damaged  in 


EXPLANATORY    NOTE    TO    PLATE    XVII. 


A  schematic  side  view  of  the  tympanum  showing  extensive  necrosis  of  the  upper 
lateral  canal  wall,  necrosis  of  the  malleus,  absence  of  the  incus  and  stapes,  and  a 
large  perforation  in  the  upper  portion  of  the  drum  membrane,  through  which  a  polyp 
protrudes. 

i,  Necrosis  of  the  canal  wall;  2,  necrosis  of  the  malleus;  3,  polyp. 

138 


PLATE  XVII 


Treatment  of  Caries  of  Tympanic  Walls.      139 

any  way.  One  should  also  avoid  penetrating  the  soft  tissues 
with  the  probe  as  far  as  possible  and  great  care  must  be 
exercised  when  the  osseous  region  under  examination  is 
diploetic,  as  this  form  of  bony  structure  seems  especially 
susceptible  to  infective  agencies  and  fresh  areas  may  be  unin- 
tentionally opened  up  and  infected,  which  will  rapidly  pro- 
duce extensive  and  even  serious  osseous  lesions. 

In  many  instances  no  positive  results  as  regards  the  pres- 
ence of  osseous  lesions  of  the  walls  will  be  ascertainable  by 
the  most  careful  probing,  and  then  in  order  to  obtain  fairly 
definite  indications  for  operative  procedures,  it  will  become 
necessary  to  base  the  diagnosis  by  the  complex  of  the  various 
symptoms  present,  so  that,  in  many  instances  at  least,  fair 
presumptive  evidence  of  the  presence  or  absence  of  caries 
may  be  obtained  in  this  way.  Of  these,  the  more  or  less 
irregular  recurrence  of  uncomfortable  sensations,  or  even 
pain,  referred  to  the  deeper  portions  of  the  ear  is  quite  sug- 
gestive of  a  carious  lesion,  especially  if  the  pain  of  reten- 
tion, as  previously  mentioned,  can  be  eliminated,  and  in  addi- 
tion it  assumes  a  more  distinct  character  as  night  approaches. 
The  secretion  from  the  middle  ear  may  contain  gritty  par- 
ticles of  bone  when  the  rcognition  of  the  condition  is  of 
course  absolute,  but  when  such  are  absent,  it  affords  little 
evidence  as  a  presumptive  sign  unless  it  is  thin,  offensive 
and  resembles  the  pus  seen  from  bone  sinuses  in  other  por- 
tions of  the  body.  Marked  changes  of  the  mucous  mem- 
brane may  be  added  to  this  group,  such  as  excessive  infiltra- 
tion, especially  of  limited  areas,  or  when  these  changes  have 
produced  polypi  or  granulation  tissue,  the  latter  rapidly  re- 
curring after  its  removal.  Excessive  infiltration  or  inflam- 
mation of  the  lining  of  the  external  auditory  canal  espe- 
cially if  associated  with  larger  or  smaller  fistulous  openings, 
is  also  of  value  in  the  cases  where  other  evidences  of  caries 
are  very  slight  or  altogether  absent,  but  it  must  also  be 


140  Suppuration  of  the  Middle  Ear. 

remembered  that  the  absence  of  these  various  symptoms  does 
not  necessarily  imply  that  caries  is  not  present. 

The  relation  between  caries  of  the  walls  and  alterations 
of  the  ossicles  is  very  intimate,  and  although  the  latter  are 
usually  involved  at  first,  yet  in  cases  of  long  standing,  the 
removal  of  these  is  not  sufficient  alone  to  cure  the  suppura- 
tion, but  it  is  also  necessary  to  curette  the  tympanic  space  in 
part  or  its  entirety,  depending  of  course  upon  the  severity 
and  extent  of  the  lesions  present.  One  should  therefore 
never  feel  satisfied  that  the  cause  of  the  suppuration  has 
been  removed  when  the  malleus  and  incus  have  been  dis- 
posed of,  as  often  this  is  but  a  single  step  in  the  complete 
operation,  and  one  cannot  consider  it  completed  until  all  the 
diseased  osseous  tissue  has  been  removed  from  the  tympanic 
cavity.  On  the  other  hand,  the  indications  are  such  that  the 
question  of  removing  the  ossicles  cannot  be  considered,  even 
if  one  or  both  should  present  slight  evidence  of  a  carious 
process  until  more  conservative  treatment  has  been  given 
a  fair  trial,  and  the  recognized  carious  areas  of  the  tym- 
panic walls  be  curetted,  if  they  be  in  such  a  position  that 
this  can  safely  be  performed.  Usually,  if  the  lesion  be  at 
all  extensive,  the  treatment  of  carious  tympanic  walls  with- 
out removal  of  the  ossicles  will  result  in  failure,  but  in  a 
smaller  moiety  of  cases,  with  the  lesion  limited  to  the  prom- 
ontory, or  possibly  a  portion  of  the  tympanic  ring  alone 
affected,  one  may  obtain  a  favorable  result,  especially  if  an 
energetic  after  treatment  be  employed. 

The  amount  of  purulent  discharge,  aside  from  its  quality, 
should  also  be  taken  into  consideration  in  determining  the 
presence  or  absence  of  osseous  lesions,  as  when  the  otorrhoea 
has  been  long  continued,  often  extending  over  a  period  of 
many  years,  and  the  discharge  is  poured  out  from  the  tym- 
panic cavity  in  large  amounts,  it  is  very  suggestive  of  caries 
of  the  tympanic  walls,  as  the  ossicles  in  such  cases  are  often 


Treatment  of  Caries  of  Tympanic  Walls.       141 

reduced  to  mere  irregular  fragments  and  play  but  a  modest 
part  in  the  suppuration  at  this  stage.  It  must  also  be  remem- 
bered that  a  profuse  discharge  means  that  a  considerable 
amount  of  tissue  necrosis  is  taking  place,  and  while  this 
does  not  always  presume  that  such  tissue  destruction  is  in 
great  part  osseous,  yet  it  is  impossible  for  such  to  occur 
during  a  more  or  less  protracted  course  without  a  certain 
degree  of  tympanic  involvement.  Further  than  this,  the 
purulent  discharge  originally  from  the  mucosa  produces 
further  changes  here  which  seriously  interfere  with  the  nu- 
trient blood  supply  to  the  osseous  tissue  which  of  necessity,  if 
it  be  sufficient,  produces  localized  carious  areas  and  when  in 
addition  to  this,  the  irritating  effect  of  the  pus  on  partially 
exposed  bone  is  considered,  one  may  be  fairly  safe  in  advis- 
ing operative  procedures  of  this  nature  in  intractable  otor- 
rhoea,  with  the  expectation  of  finding  the  tympanic  walls 
more  or  less  necrosed. 

While  the  treatment  of  the  conditions  described  embraces 
the  care  of  the  entire  tympanic  cavity,  yet  in  many  ways  it  is 
more  practicable  to  divide  this  cavity  into  two  portions,  the 
attic,  or  epitympanic  space,  and  the  atrium,  or  lower  tym- 
panic space,  and  especially  is  this  advisable  on  account  of 
the  preponderance  of  severe  morbid  changes  in  the  former 
situation.  With  the  brunt  of  the  suppurative  inflammation 
borne  by  the  attic,  one  finds  that  most  frequently  its  external 
wall  is  involved,  as  its  vascular  supply  is  limited,  and  it  is 
in  close  association  with  the  inflammation  of  the  attical  con- 
tents, its  structure  being  formed  by  the  auditory  plate.  The 
internal  wall,  however,  is  but  seldom  affected,  and  when 
it  does  become  involved  the  patient  is  apt  to  complain  of 
some  degree  of  vertigo  from  the  inflammation  involving  the 
stapes  and  vestibule.  When  the  pars  epitympanica  becomes 
carious  the  opening  in  Shrapnell's  membrane  is  very  apt  to 
be  irregular  in  outline  from  the  erosion  of  this  margin  of 


142  Suppuration  of  the  Middle  Ear. 

the  bony  wall,  or  when  the  vault  of  the  tympanum  is  involved 
with  or  without  the  pars  epitympanica  being  markedly 
affected,  the  perforation,  as  mentioned  in  another  chapter, 
is  located  in  the  postero-superior  quadrant  of  the  mem- 
brana  tympani,  and  usually  just  below  the  location  of  the 
incudo-stapedial  joint,  while  the  lower  portion  of  the  mem- 
brane is  very  apt  to  be  adherent  to  the  inner  osseous  wall, 
the  superior  portion  remaining  free.  These  characteristics 
of  tympanic  caries  result  from  the  manner  in  which  the  pus 
travels  from  this  region  to  escape  in  a  lower  position,  and 
this  is  accomplished  by  the  fluid  flowing  down  the  long 
process  of  the  incus;  the  purulent  matter  being  restricted 
to  this  route  in  cases  where  the  ossicles  have  not  been  de- 
stroyed, as  it  is  the  only  portion  of  the  ossicular  chain  which 
passes  directly  from  the  attic  down  into  the  atrium.  In 
some  cases  it  is  possible  to  determine  the  presence  of  caries 
by  a  sinus  leading  directly  into  the  vault  of  the  tympanum 
and  granulation  tissue  protruding  from  the  mouth  of  the 
sinus  is  almost  certain  evidence  that  an  osseous  lesion  is 
present.  A  mass  of  granulation  tissue  arising  from  the  pos- 
terior and  superior  portion  of  the  tympanum  is  also  strongly 
suggestive  of  the  same  origin,  and  probably  in  the  imme- 
diate neighborhood  of  the  antrum,  the  amount  of  purulent 
discharge  being  somewhat  of  value  in  determining  the  extent 
of  the  lesion,  as,  if  it  is  profuse,  one  would  be  inclined  to 
consider  the  lesion  of  considerable  extent,  while,  were  it 
scanty  in  amount,  the  area  of  bone  necrosis  would  probably 
be  small  and  possibly,  as  in  some  of  these  cases,  aside  from 
the  ossicular  involvement,  limited  to  but  the  small  edge  of 
bone  forming  the  entrance  to  the  antrum. 

The  removal  of  the  outer  attical  wall  is  indicated  in  those 
cases  where  the  perforation  is  in  Shrapnell's  membrane  and 
the  residue  of  the  purulent  inflammation  is  apparently  lim- 
ited to  the  region  of  the  attic,  and  in  which  there  is  but  little 


Treatment  of  Caries  of  Tympanic  Walls.      143 

disturbance  of  audition,  so  that  the  ossicles  are  not  exten- 
sively involved  and  should  not  be  removed,  the  excision  of 
the  carious  external  wall  with  the  removal  of  the  morbid 
tissue  from  the  vault  usually  being  all  that  is  indicated. 
The  method  of  removing  this  bony  wall  may  be  by  simple 
curettage  with  a  sharp  spoon  or  by  a  punch.  The  sharp 
spoon  is  employed  in  removing  this  portion  of  the  tympanic 
margin  by  cutting  away  the  carious  bone  by  firm  pressure 
from  behind  forward,  care  being  taken  that  the  malleus 
and  incus  are  not  injured,  and  by  curetting  the  bone  away, 
which  is  usually  quite  soft  at  its  inferior  border,  the  external 
attical  space  may  be  sufficiently  opened  to  remove  the  ob- 
struction to  free  drainage,  or  in  case  the  caries  is  to  a  great 
extent  limited  to  the  margo  tympanicus,  its  removal  in  this 
manner  will  be  sufficient.  As  an  independent  operative  pro- 
cedure, the  removal  of  the  pars  epitympanica  alone  is  but 
rarely  indicated,  as  it  is  exceptional  to  find  caries  involving 
this  part  without  involvement  of  the  incus.  Should  the 
tympanic  caries  be  extensive,  the  removal  of  the  pars  by  way 
of  the  canal  will  not  be  sufficient,  and  then  a  procedure  such 
as  Stacke's  operation  will  be  indicated.  Another  method  of 
opening  the  attic  is  by  the  removal  of  its  external  wall  with 
a  forceps-chisel,  of  which  several  varieties  may  be  obtained. 
The  perforation  in  the  membrana  tympani  should  be  en- 
larged if  necessary,  so  that  the  instrument  may  be  inserted 
into  the  tympanum  and  its  anterior  hook-shaped  portion 
grasp  the  inner  portion  of  the  external  attic  wall.  In  this 
way  the  bony  plate  which  is  to  be  removed  lies  between 
the  hook-like  plate  of  the  instrument  on  its  inner  side  and 
the  chisel  portion  externally.  This  procedure  is  repeated 
several  times,  when  the  instrument  is  withdrawn  in  order  to 
remove  the  small  pieces  of  bone  from  it  and  to  control  bleed- 
ing and  see  the  amount  of  tissue  removed,  and  if  some 
necrosis  is  still  present,  the  chisel  is  again  placed  in  position 


144  Suppuration  of  the  Middle  Ear. 

and  particles  of  bone  removed  in  the  same  manner  until  all 
the  involved  tissue  has  been  cut  away.  With  some  of  the 
newer  models  of  this  instrument,  it  is  surprising  how  rap- 
idly and  how  safely  the  external  attic  wall  can  be  removed 
and  with  a  minimum  of  danger;  the  greatest  care  being 
required,  however,  that  the  ossicles  do  not  become  displaced 
from  pushing  the  end  of  the  instrument  too  far  inward. 
Of  course  one  cannot  expect  to  remove  the  wall  here  as 
thoroughly  through  the  canal  as  by  a  post-auricular  oper- 
ation, but  if  the  area  of  caries  be  small  and  no  other  indica- 
tions exist  for  the  larger  operation,  it  is  often  possible  to 
materially  aid  the  chronic  suppuration  by  removing  the 
carious  bony  tissue  in  this  way.  This  method  of  opening 
the  attic,  while  of  value  in  practically  all  cases  where  the 
carious  process  is  not  too  extensive,  is  of  special  service  in 
those  cases  where  the  suppurative  inflammation  has  in  great 
part  become  limited  to  the  external  attic  space,  that  is,  that 
portion  lying  between  the  malleus  and  incus  internally  and 
the  wall  of  the  tympanum  externally.  In  such  cases  of  the 
so-called  external  atticitis  the  purulent  discharge  is  usually 
quite  scanty,  there  is  but  little  or  no  odor  except  when  reten- 
tion takes  place  for  a  lengthy  period  and  the  perforation  is 
in  Shrapnell's  membrane,  often  in  intimate  relation  with 
the  carious  edge  of  the  attic  wall,  so  that  here  one  often 
finds  a  small  patch  of  granulation  tissue  concealing  the  dead 
bone.  As  shown  by  Batey,  this  form  of  atticitis  is  the  result 
of  the  chronic  tympanic  suppuration  finally  becoming  local- 
ized in  the  external  attic,  and  as  the  head  of  the  malleus, 
with  the  body  and  short  process  of  the  incus,  project  into 
the  attic,  they  form,  in  conjunction  with  its  external  wall, 
a  more  or  less  confined  space  into  which  the  pus  can  drain 
from  the  parts  superior  and  posterior  to  it.  By  removing 
the  external  retaining  wall  in  the  way  heretofore  described, 
that  is,  either  by  curette  or  forceps-chisel,  an  open  space  is 


Treatment  of  Caries  of  Tympanic  Walls.      145 

made  of  this  heretofore  enclosed  area,  and  if  the  granula- 
tion tissue  usually  present  be  snared  or  curetted  away,  one 
is  often  able  in  such  cases  to  obtain  a  comparatively  large 
space  with  no  restriction  of  drainage,  so  that  the  suppura- 
tive  process  either  heals  within  a  very  short  time  or  after 
additional  local  treatment  which  can  now  be  readily  carried 
out  so  that  the  ossicles  can  be  allowed  to  remain  in  situ  and 
a  Stacke  or  other  more  radical  operation  will  be  avoided. 

When  the  epitympanic  regions  are  curetted  through  the 
canal,  certain  disadvantages  are  necessarily  encountered 
which  are  not  present  when  the  field  of  operation  is  laid 
bare,  as  in  the  post-auricular  operations.  Unfortunately, 
even  when  the  pars  epitympanica  has  been  thoroughly  re- 
moved, the  attic  must  be  in  great  part  curetted  by  touch 
alone,  as  it  is  impossible  to  see  all  that  is  being  done.  For 
this  reason  one  must  always  proceed  most  cautiously  in 
this  region,  and  further,  it  is  not  always  possible  to  ascer- 
tain that  all  diseased  tissue  here  has  been  removed,  although 
the  careful  use  of  the  probe  used  to  locate  any  carious 
areas  will  be  of  great  value  in  aiding  one  to  eliminate 
all  the  diseased  tissue  in  a  large  number  of  cases.  But  it 
is  much  more  satisfactory  and  probably  will  conserve  the 
interest  of  the  patient  more  efficiently  if  operation  through 
the  canal  be  refused  in  cases  where  the  attic  and  possibly 
the  antrum  show  extensive  lesions  and  one  is  in  doubt  as 
to  the  ability  to  remove  all  the  morbid  tissue.  Another 
method  of  removing  the  pars  epitympanica  to  obtain  access 
to  the  attic  region  is  by  the  use  of  the  burr  driven  either 
by  the  electric  motor  or  the  ordinary  dental  engine.  This 
has  been  used  to  some  extent  abroad,  but  in  this  country  the 
cylindrical  burr  used  for  this  purpose  has  not  proven  as 
satisfactory  as  the  curette  or  forceps-chisel,  although  by  its 
use  the  attic  wall  can  be  quickly  and  easily  removed,  some 
cases  having  been  recorded  in  which  the  whole  of  the  antrum 

ii 


146  Suppuration  of  the  Middle  Ear. 

has  been  thus  exposed.  In  using  this  instrument  it  is  abso- 
lutely essential  that  the  external  auditory  canal  be  very 
broad  and  not  too  deep,  so  that  a  burr  with  a  short  shank 
may  be  employed.  If  the  attic  alone  is  to  be  opened,  Strum 
advises  the  use  of  local  anaesthesia,  but  where  it  is  to  be 
employed  in  removing  carious  bone  from  other  areas,  such 
as  the  inner  tympanic  wall,  general  anaesthesia  then  becomes 
necessary,  and  this  author  also  finds  that  in  opening  the  attic 
wall  the  instrument  readily  penetrates  the  thin  dermal  lining 
of  the  canal,  so  that  section  of  this  part  is  unnecessary, 
while  the  only  untoward  effects  seen  after  the  employment 
of  this  instrument  here  has  been  some  tinnitus,  which  always 
subsided  after  a  short  time. 

The  portions  of  the  tympanic  cavity  and  its  neighboring 
osseous  relations  most  frequently  involved  in  the  carious 
process,  and  which  may  be  reached,  in  part  at  least,  through 
the  canal,  are  especially  the  tegmen  and  outer  wall  and  the 
portion  of  the  external  wall  in  close  connection  with  the 
tympanic  cavity,  which  is  formed  by  the  auditory  plate  of 
the  temporal  bone.  Where  the  tissue  is  in  this  way  pneu- 
matic in  structure,  it  is  much  more  frequently  involved  than 
the  compact  or  diploetic  osseous  tissue,  as  the  latter  presents 
a  much  greater  degree  of  resistance  to  the  purulent  infec- 
tion than  does  the  former,  the  postero-superior  wall  of  the 
external  canal  being  usually  involved,  then  the  wall  of  the 
promontory,  the  tegmen  tympani  and  the  anterior  wall  of 
the  meatus  usually  following  in  the  order  named.  This  is, 
however,  not  at  all  constant,  as  the  parts  involved  at  first 
in  the  carious  process,  irrespective  of  their  location,  are  those 
that  are  the  least  vascular  and  in  which  the  nutrient  vessels 
are  readily  interfered  with  by  changes  in  the  tympanic  mu- 
cous membrane  or  by  any  increase  of  pressure  in  the  tym- 
panic cavity.  Rarely  it  occurs  that  a  single  area  is  carious, 
such  as  a  small  spot  on  the  promontory,  but  as  a  rule  several 


Treatment  of  Caries  of  Tympanic  Walls.      147 

carious  areas  are  found  and  if  the  mucosa  be  greatly  in- 
volved, all  the  anatomical  points  mentioned  will  be  found  to 
be  more  or  less  affected.  While  the  basal  cause  of  the  caries 
of  the  tympanic  walls  is  the  serious  interference  with  the 
blood  supply  as  previously  pointed  out,  local  causes  are  essen- 
tial to  bring  about  this  condition,  Politzer  classifying  as  the 
most  important  of  these  local  agents  the  retention  of  pus  in 
the  middle  ear  from  stricture  of  the  canal;  the  presence  of 
polypi,  granulation  tissue  and  cholesteatoma  and  stagnation 
and  decomposition  of  the  purulent  discharge,  or  of  an  accu- 
mulation of  epidermic  masses  which  produce  ulceration  of 
the  mucous  membrane  of  the  tympanic  cavity  and  thus  ex- 
posing and  causing  caries  of  its  underlying  osseous  walls. 
This  is  in  great  part  favored  by  the  mucosa  acting  both  as  a 
mucous-membrane  lining  for  the  tympanum  and  also  as  its 
periosteum  carrying  the  nutrient  blood  supply.  The  result 
of  this  is  well  shown  by  the  more  extensive  osseous  destruc- 
tion taking  place  in  children  than  in  adults,  on  account  of  the 
structure  of  the  periosteal  layer  of  the  mucous  membrane  in 
the  former  being  greatly  more  vascular  and  containing  rela- 
tively more  numerous  and  larger  vessels  than  pass  into  the 
osseous  tissue.  General  morbid  states  may  also  play  a  prom- 
inent part  in  determining  the  rapidity  and  extent  of  the 
osseous  involvement,  as  in  syphilis  and  tuberculosis,  the  pro- 
fuse formation  of  pus  with  its  retention  at  times  allows  the 
pathological  organisms  to  invade  the  mucosa  to  a  greater 
degree  and  with  the  inflammation  thus  produced  of  its  deeper 
layers  the  round  cell  infiltration  obliterates  the  vascular  chan- 
nels, and  shutting  off  the  blood  supply,  causes  the  periosteal 
layer  to  separate  from  the  underlying  bone  with  its  subse- 
quent necrosis. 

The  indications  for  removing  the  carious  areas  must  of 
necessity  greatly  vary  in  almost  every  case,  and  especially 
so  in  that  group  where,  on  account  of  the  suppuration,  radi- 


148  Suppuration  of  the  Middle  Ear. 

cal  operation  must  also  be  taken  into  serious  consideration. 
Such  cases  in  which  operation  through  the  canal  for  this 
purpose  is  indicated  instead  of  post-auricular  opening  of  the 
antrum  and  attic,  are  those  in  which  the  membrana  tympani 
has  been  in  great  part  destroyed  and  the  mucous  membrane 
of  the  cavum  tympani  has  undergone  a  considerable  amount 
of  hyperplasia  with  but  slight  osseous  changes,  although 
small  carious  areas  may  be  present  on  the  inner  tympanic 
wall.  Another  group  belonging  to  this  class  shows  usually 
a  small  irregularly  placed  perforation  of  the  membrana,  and 
there  is  a  constant  tendency  for  the  suppuration  to  cease, 
then  to  recur  again  on  the  slightest  causes,  such  as  an  attack 
of  coryza.  In  these  cases  the  patient  is  not  annoyed  in  any 
way  by  his  aural  condition  when  the  discharge  is  absent, 
as  it  not  infrequently  happens  at  such  times  that  the  per- 
foration entirely  closes,  while  again  the  discharge  comes  on 
and  relief  is  sought  only  for  this  annoying  tendency  to  the 
recurrence  of  the  discharge.  Another  class  has  been  de- 
scribed where  the  problem  of  deciding  what  operation  to 
perform  is  somewhat  difficult,  and  that  is  in  those  patients 
with  good  hearing,  but  a  constant  suppuration  of  both  ears ; 
no  immediate  indications  for  operative  procedure  being  pres- 
ent except  the  continued  purulent  discharge.  In  such  cases 
antiseptic  treatment  should  be  continued  for  many  months, 
and  then  if  no  impression  be  made  upon  the  affection,  it 
seems  the  best  plan  to  remove  the  carious  bone  from  the  walls 
without  disturbing,  as  far  as  possible,  the  ossicles,  one  ear 
being  treated  in  this  manner  and  the  other  allowed  to  remain 
free  from  operative  interference  until  the  process  has  been 
conquered  if  such  be  possible  in  this  way,  and  if  no  impair- 
ment of  hearing  results,  then  the  other  ear  may  be  curetted 
in  the  same  manner. 

The  changes  in  the  osseous  walls  as  the  result  of  the  sup- 
purative  process  vary  in  the  different  portions  of  the  tym- 


Treatment  of  Caries  of  Tympanic  Walls.      149 

panum,  depending  upon  the  extent  of  the  diseased  process 
and  the  resistance  of  the  bony  tissue.  In  one  part  the  bone 
may  be  degenerated  and  undergoing  absorption,  in  another 
part  the  carious  and  necrotic  process  is  so  marked  that  the 
bone  at  that  point  is  in  process  of  exfoliation.  Surrounding 
the  carious  areas,  the  bone  is  usually  much  harder  than  nor- 
mal, as  the  result  of  the  growth  of  cells  into  it  from  the  muco- 
periosteum,  so  that  the  increased  vascular  dilatation  in  such 
areas  with  an  augmentation  of  the  bone  cells,  produces  this 
condensation  with  the  development  of  a  hyperplastic  condi- 
tion. Where  the  process  has  been  latent  and  of  long  evolu- 
tion, the  spaces  in  the  bone  at  first  filled  with  granulation 
tissue,  later  become  ossified  and  the  walls  so  affected  become 
increased  in  thickness,  thus  isolating  to  a  greater  extent  than 
usual  the  suppurating  middle  ear  from  the  surrounding 
parts,  as  it  were,  and  as  this  newly  formed  osseous  tissue 
also  loses  its  nutrition,  necrosis  will  be  found  in  the  areas 
of  the  thinner  parts.  Over  these  carious  or  necrotic  areas, 
gray  colored  unhealthy  masses  of  granulations  spring  up, 
while  the  mucosa  is  ulcerated,  and  if  the  soft  tissues  should 
be  removed  without  curetting  the  carious  bone  they  rapidly 
recur  again  and  in  neglected  cases  after  the  tympanic  cavity 
has  been  cleansed  of  these  granulation  masses  often  mixed 
with  epithelial  debris  and  inspissated  decomposed  pus,  one 
often  finds  the  walls  of  the  cavity  eroded  in  one  place,  while 
in  another  the  thickened  wall  will  show  projections  of  most 
irregular  shape  and  form  of  osseous  outgrowth,  which  will 
require  a  fairly  strong  sharp  spoon  for  their  removal.  Ex- 
foliated spicules  of  bone  from  the  overgrowth  of  the  walls 
in  part  and  not  from  the  partially  destroyed  malleus  and 
incus  are  also  occasionally  found  and  must  be  removed  with 
forceps  and  in  some  instances  a  well-marked  ulceration  may 
be  seen  in  the  wall  of  the  promontory,  penetrating  into  the 
bony  lamella  of  the  labyrinth,  although  the  osseous  tissue 


150  Suppuration  of  the  Middle  Ear. 

may  not  be  seriously  damaged,  as  only  its  superficial  layer 
is  affected;  the  apparent  depth  of  the  ulceration  resulting 
from  the  increase  in  thickness  of  the  greatly  hypertrophied 
mucosa. 

After  the  carious  tissue  has  been  accurately  determined 
by  the  probe,  either  before  or  after  the  exuberant  granula- 
tion tissue  has  been  curetted  away,  as  must  be  determined 
in  the  individual  case,  the  softened  bone  should  be  removed 
with  the  curette,  the  amount  of  force  used  being  determined 
by  the  location  of  the  involved  tissue,  but  at  no  time  should 
it  be  excessive,  as  serious  damage  may  ensue.  The  curette 
must  vary  in  shape  and  size,  depending  upon  the  location  of 
the  carious  tissue;  for  the  lower  tympanic  space  it  may  be 
straight,  while  for  the  attic  it  is  necessary  to  use  sharp  spoons 
bent  at  various  angles,  a  right-angle  spoon,  however,  always 
being  necessary,  and  when  curetting  these  parts,  it  should 
be  remembered  that  although  the  ossicles  may  be  removed 
and  the  morbid  mucous  membrane  extirpated,  the  success 
or  failure  of  the  operation  will  depend  on  the  thoroughness 
with  which  necrotic  and  carious  areas  of  the  tympanic  walls 
have  been  removed.  As  has  been  pointed  out  by  Politzer,  in 
many  cases  of  tympanic  wall  caries  the  curetting  is  suc- 
cessful only  when  the  carious  process  has  not  extended  to 
too  great  a  depth,  for  if  it  be  deeply  seated  the  curetting  will 
not  prove  of  much  service,  and  as  it  is  not  always  possible 
to  tell  by  the  probe  the  depth  in  the  bone  to  which  the  process 
has  extended,  one  should  never  curette  to  a  greater  depth 
than  one  or  two  millimeters,  as  a  penetration  deeper  than 
this  may  enter  into  the  cranial  cavity  or  labyrinth.  Should 
the  caries  be  limited  in  extent  and  but  slightly  superficial, 
gentle  curetting  will  usually  be  sufficient  to  bring  about  the 
restoration  to  the  normal  of  the  parts,  particularly  if  the 
morbid  tissue  filling  the  tympanic  cavity  in  part  or  whole  be 
removed  so  that  the  freshly  curetted  walls  are  kept  free  from 


Treatment  of  Caries  of  Tympanic  Walls.      151 

the  irritation  and  reinfection  of  the  purulent  secretion  for  a 
short  time.  Either  in  this  form  of  superficial  caries  or  when 
the  bone  is  more  seriously  involved,  the  sharp  curette  should 
always  be  used  in  preference  to  the  dull  instrument,  which 
is  of  value  in  removing  granulation  tissue  in  certain  situa- 
tions and  when  the  caries  is  well  defined  it  should,  as  far  as 
practicable,  be  entirely  removed,  the  ring  curette  or  sharp 
spoon  being  very  efficient  for  this  purpose. 

While  it  is  not  usual  to  find  caries  of  any  consider- 
able moment  in  the  hypotympanic  space,  yet  such  a  condi- 
tion does  occur  and  great  circumspection  must  be  used  in 
curetting  the  diseased  area  if  such  be  found  here.  When 
it  does  occur  in  this  locality  it  is  apt  to  involve  the  small 
pneumatic  spaces  which  in  some  cases  connect  the  infe- 
rior tympanic  floor  with  the  carotid  canal,  and  one  must 
cautiously  explore  these  spaces,  if  they  be  present,  in  order 
to  remove  all  the  dead  bone  if  such  can  be  done  without 
danger  to  the  important  structures  here,  the  air  cells  of  this 
region  sometimes  extending  externally  between  the  lamella 
of  the  anterior  and  inferior  walls  of  the  external  canal.  One 
should  be  careful  when  using  the  curette  in  the  tympanic 
cavity  to  differentiate  between  dead  and  healthy  bone,  as  it 
does  not  necessarily  follow  that  because  an  area  of  bone  has 
for  any  reason  been  exposed  that  it  is  carious,  and  if  such 
a  bare  osseous  surface  be  healthy  in  appearance  and  not 
rough  in  any  way,  it  is  very  probable  that  it  is  healthy  and 
should  not  be  touched.  If  there  be  any  doubt  as  to  the  via- 
bility of  the  exposed  area,  however,  and  it  seems  impossible 
to  determine  this  question,  if  other  dead  bone  be  present  it 
is  usually  advisable  to  curette  all  the  suspected  areas,  as  the 
entire  success  of  the  operation  may  be  seriously  compromised 
if  some  of  these  changes,  which  seem  doubtful  or  trifling  in 
extent,  are  not  removed,  but  are  left  to  remain  to  act  as  foci 
for  further  suppuration. 


152  Suppuration  of  the  Middle  Ear. 

In  some  cases  of  chronic  suppuration,  although  more 
frequent  in  acute  cases  following  the  exanthemata,  one  may 
find  well-marked  areas  of  superficial  necrosis  with  seques- 
trum formation.  This  occurs  most  frequently  at  the  pos- 
tero-superior  portion  of  the  external  canal  wall  and  may 
be  rarely  discharged  in  the  pus,  or  more  frequently  be  par- 
tially detached  as  a  curved,  semilunar,  irregular  scroll  of 
bone,  with  its  internal  edge,  if  it  be  not  too  much  eroded, 
showing  the  border  of  this  part  of  the  sulcus  tympanicus. 
When  found  in  situ  it  is  usually  entirely  covered  over  with 
a  mass  of  granulation  tissue  and  is  not  detected  until  search 
with  the  probe  for  carious  bone  reveals  this  detached  osseous 
sequestrum,  which  may  sometimes  be  removed  with  forceps, 
or  again  is  still  so  firmly  attached  that  it  is  impossible  to 
remove  it  without  further  operative  procedures.  One  may 
also  find  a  thin  sequestrum  detached  from  the  region  of  the 
promontory  as  a  result  of  the  superficial  caries  and  necrosis 
of  this  portion  of  the  tympanic  walls,  and  like  that  described, 
it  may  be  entirely  covered  with  the  thickened,  granulating 
mucous  membrane,  which  has  to  be  curetted  away  before  the 
irregular  plate  of  necrosed  bone  can  be  removed.  This 
sequestrum  may,  as  in  some  reported  cases,  show  upon  its 
outer  surface  a  portion  of  Jacobson's  sulcus  for  the  trans- 
mission of  the  tympanic  branch  of  the  glosso-pharyngeal 
nerve,  and  thus  if  this  detached  bone  be  found  lying  free 
in  the  tympanic  cavity,  the  presence  of  these  marks  will 
afiford  a  valuable  clue  as  to  its  source  and  the  location  of  the 
necrotic  area. 

The  removal  of  a  small  sequestrum  of  bone  from  the 
tympanic  cavity  depends  upon  its  size  and  shape  in  rela- 
tion to  the  capacity  of  the  external  auditory  canal.  If  small 
and  lying  free  in  the  tympanum,  it  can  readily  be  extracted 
with  any  small  forceps  firm  enough  to  grasp  it.  In  other 
instances,  however,  it  may  be  deeply  seated,  or  in  an  inac- 


Treatment  of  Caries  of  Tympanic  Walls.      153 

cessible  portion  or  may  again  be  deeply  embedded  beneath 
a  mass  of  granulation  tissue  and  if  not  too  hard,  when  its  size 
will  not  allow  its  removal  through  the  canal,  an  attempt  may 
be  cautiously  made  to  crush  it,  when,  if  this  is  successful,  it 
can  readily  be  removed  with  forceps  or  by  syringing.  In 
some  cases,  however,  this  will  be  impossible  and  detachment 
of  the  auricle  with  or  without  removal  of  portions  of  the 
osseous  wall  of  the  external  canal  will  be  necessary  before 
it  can  be  extracted.  After  the  walls  of  the  tympanic  cavity 
have  been  curetted  and  all  necrosed  and  carious  tissue  re- 
moved, one  should  then  carefully  examine  the  tympanic  ring, 
as  it  is  frequently  involved  to  a  greater  or  lesser  degree. 
This  is  especially  so  in  regard  to  its  superior  and  postero- 
superior  margins,  as  in  this  part  it  is  in  very  intimate  rela- 
tion with  the  ossicles  and  forming  as  it  does  part  of  the 
floor  of  the  epitympanic  space,  it  is  especially  liable  to  carious 
processes  at  these  points.  Should  the  ring  be  involved  to 
any  great  extent  in  conjunction  with  morbid  changes  in  the 
tympanic  cavity,  it  will  be  almost  useless  to  attempt  to  oblit- 
erate the  diseased  parts  by  way  of  the  external  canal,  as  in 
such  cases  it  is  usually  found  that  the  caries  also  involves  the 
antrum  and  possibly  the  mastoid  cells,  and  is  of  course  inac- 
cessible through  the  canal.  In  cases,  however,  where  the 
bone  shows  some  softening  or  roughness  over  a  limited  area 
it  should  be  treated  the  same  as  the  walls  of  the  tympanum, 
and  with  sharp  spoon  or  curette  the  diseased  tissue  should 
be  removed  down  to  firm  healthy  bone,  or  if  desired  the  part 
of  the  ring  involved  may  be  excised  with  cutting  forceps  and 
then  smoothed  down  with  the  curette. 

Finally  in  all  cutting  operations  for  the  removal  of 
carious  or  necrosed  bone,  either  from  the  walls  of  the  tym- 
panum or  its  immediate  vicinity,  one  must  always  bear  in 
mind  that  certain  dangerous  elements  are  always  present. 
Of  the  least  of  these,  nausea  and  vertigo  often  occur,  but  are 


154  Suppuration  of  the  Middle  Ear. 

usually  transient  and  result  from  some  temporary  trauma- 
tism  to  the  stapes,  while  as  more  serious  may  be  noted  facial 
paralysis,  which  readily  disappears  within  a  short  time  if  the 
nerve  has  not  been  too  seriously  damaged,  and  one  may  also 
perforate  into  the  cranial  cavity  through  the  tegmen  tympani, 
when  the  curetting  should  be  immediately  stopped  and  a  post- 
auricular  operation  performed  to  remove  all  the  necrosed 
bone,  and  thus  protect  the  cranial  contents  from  infection. 


CHAPTER  VI. 

THE   AFTER  TREATMENT   OF   OPERA- 
TIONS THROUGH  THE  EXTERNAL 
AUDITORY  CANAL. 


'55 


THE  AFTER  TREATMENT  OF  OPERATIONS  THROUGH  THE 
EXTERNAL  AUDITORY  CANAL. 

When  an  ossiculectomy  has  been  performed,  granulations 
and  cholesteatomatous  tissue  removed,  or  the  tympanic  wall 
curetted  to  remove  carious  bone,  much  has  been  done  towards 
the  desired  aim  of  relieving  the  patient  of  the  suppurative 
otitis  media,  but  if  minute  and  careful  attention  be  not  given 
to  the  after  treatment  of  these  cases  little  will  ultimately 
be  accomplished  in  the  vast  majority,  as  this  care  of  the 
tympanic  cavity,  both  in  order  to  obtain  prompt  resolution 
of  the  tissues  which  still  remain,  and  to  prevent  by  careful 
attention  to  details  the  further  breaking  down  of  other  tis- 
sues, is  always  essential  in  every  case  where  operation  has 
been  performed  through  the  external  canal.  In  other  words, 
the  various  operative  procedures  performed  in  this  way  have 
been  aptly  described  as  being  only  steps  towards  the  perma- 
nent relief  of  the  suppuration,  the  local  care  of  the  affected 
tissue  after  the  operation,  being  fully  as  important,  and 
during  this  after  treatment  it  should  always  be  borne  in  mind 
that  in  obstinate  cases  the  curetting  of  newly  formed  granu- 
lation tissue  or  the  removal  of  additional  areas  of  carious 

157 


158  Suppuration  of  the  Middle  Ear. 

bone,  will  from  time  to  time  frequently  be  necessary.  The 
main  element  of  success  in  the  treatment  of  such  cases  is 
the  scrupulous  attention  to  minor  details,  with  patient  watch- 
fulness as  regards  the  care  of  the  tympanic  cavity. 

As,  for  sake  of  clearness  the  various  operations  upon 
the  tympanic  walls  and  its  contents  have  been  described  in 
the  previous  chapters  as  independent  operations,  but  which 
are  one  or  all  performed  at  the  same  time  in  many  cases,  so 
it  is  desired  here  to  consider  the  treatment  following  opera- 
tion in  the  same  manner  as  more  clearly  descriptive  of  the 
various  conditions.  After  a  perforation  in  the  membrana 
tympani  has  been  enlarged,  or  a  second  perforation  made 
in  order  to  evacuate  retained  pus,  the  parts  should  be  cleansed 
with  an  antiseptic  solution,  such  as  1 : 5000  bichloride  solu- 
tion, and  the  inspissated  material  usually  present  washed 
out  of  the  tympanic  cavity  with  a  delicate  cannula,  or  pref- 
erably, Blake's  intratympanic  syringe,  until  the  fluid  comes 
away  perfectly  clear.  The  parts  are  then  mopped  with  a 
sterile  cotton  tuft  dipped  in  peroxide  of  hydrogen  solution, 
and  this  is  alternately  repeated  until  free  drainage  is  ob- 
tained and  the  portions  of  the  tympanic  cavity  accessible 
through  the  perforation  or  perforations,  with  the  external 
auditory  canal,  are  rendered  as  clean  as  possible.  Upon  the 
amount  of  purulent  secretion  discharged  from  the  tympanum 
does  the  further  treatment  depend.  Should  the  discharge 
be  profuse,  the  external  meatus  is  lightly  closed  with  cotton 
and  the  ear  should  be  syringed  frequently  with  a  warm,  nor- 
mal salt  solution;  in  other  cases,  after  cleansing  the  canal, 
sterile  or  iodoform  gauze  strips  are  lightly  packed  into  it, 
reaching  well  to  the  perforation,  and  the  parts  are  then 
drained  into  a  cotton  pledget  placed  at  the  external  orifice, 
and  which  may  be  changed  by  the  patient  should  it  become 
moist,  but  under  no  circumstances  should  he  be  allowed  to 
disturb  the  gauze  drain.  In  still  another  group,  where  the 


Operations  through  External  Auditory  Canal.     159 

discharge  is  scant,  the  best  results  have  seemingly  been  ob- 
tained by  gently  dusting  over  the  membrana  tympani  and 
walls  of  the  canal  an  antiseptic  drying  powder,  such  as  boric 
acid,  acetanilide,  or  those  containing  iodine,  these  latter  being 
of  the  most  service  in  the  majority  of  instances. 

When  the  membrana  tympani  has  been  removed  in  its 
entirety  as  a  preliminary  procedure  for  an  ossiculectomy  or 
curettage  of  the  tympanum,  the  treatment  becomes  part  of 
the  operation  of  which  this  procedure  is  but  a  part,  and  in 
itself  requires  no  special  mention  except  that  when  it  shows 
a  tendency  to  reform  as  a  cicatricial  membrane  it  should  be 
removed  as  previously  described  and  the  annulus  lightly 
cauterized  at  several  points  with  chromic  acid  or  nitrate  of 
silver,  unless  the  suppuration  of  the  tympanum  has  ceased, 
when  the  question  of  its  presence  or  absence  depends  entirely 
upon  the  hearing  and  its  effects  upon  it. 

As  a  cardinal  principle  in  the  after  treatment  of  these 
various  operations  through  the  external  canal,  the  nearer  one 
approaches  a  strictly  aseptic  plane  the  more  promising  will 
be  the  final  results,  and  not  only  should  this  surgical  clean- 
liness be  enforced  in  regard  to  the  tympanic  cavity  and  ex- 
ternal auditory  canal,  but  that  portion  of  the  auricle  in  rela- 
tion thereto  should  also  be  carefully  kept  cleansed  in  order 
that  the  entrance  of  further  infective  material  be  prevented 
to  as  great  an  extent  as  possible.  While  such  precautions 
may  seem  not  only  unnecessary  but  also  entirely  useless  in 
the  treatment  of  a  suppurating  ear  already  infected,  yet  such 
is  not  the  case  by  any  means,  as  this  adherence  to  strict  anti- 
septic surgical  principles  has  a  two-fold  purpose,  both  by 
preventing  to  a  great  extent  the  entrance  of  further  and 
possibly  more  serious  infective  material  into  the  already  dis- 
eased parts,  and  secondly,  it  aids  in  diminishing  both  the 
quantity  and  virulency  of  the  organisms  already  present. 
While  the  desired  surgical  cleanliness  as  regards  the  tissues 


160  Suppuration  of  the  Middle  Ear. 

at  the  most  can  be  but  relative,  yet  as  concerns  the  instru- 
ments and  dressings  used  in  the  after  treatment,  it  can  and 
should  be  absolute  and  nothing  should  be  placed  in  the  ex- 
ternal canal,  including  even  the  speculum,  but  what  has  been 
properly  sterilized.  This  care  is  especially  important  as 
regards  the  dressings  used,  as  it  is  impossible  to  expect  a 
suppurating  ear  to  cease  discharging  unless  the  gauze  used 
in  draining  the  canal,  for  instance,  be  sterile,  and  it  is  also 
highly  important  in  this  connection  to  remove  the  dressings, 
if  such  be  used,  before  the  purulent  discharge,  if  profuse,  has 
saturated  them,  so  that  no  added  danger  of  retention  and 
increased  infection  of  other  tissues  can  take  place  in  this 
way.  In  this  respect  one  can  safely  premise,  as  a  general 
rule,  that  if  more  attention  was  paid  to  the  strict  aseptic 
treatment  of  cases  of  chronic  suppurative  otitis,  as  far  as 
consistent  with  the  nature  of  the  parts  after  such  operative 
procedures  here,  the  number  of  cases  in  which  the  suppura- 
tion was  eradicated,  and  radical  operation  was  thereby  pre- 
vented, would  be  markedly  increased,  as  it  seems  very  prob- 
able that  an  unnecessary  number  of  failures  or  partial  suc- 
cesses result  from  neglect  of  this  highly  important  principle. 
After  a  single  large  polypus  or  a  circumscribed  polypoid 
mass  of  granulation  tissue  has  been  snared  away,  the  base 
and  its  immediate  vicinity  should  be  carefully  searched  for 
necrosed  bone,  and  if  such  be  present,  it  should  be  removed 
as  previously  pointed  out,  the  after  treatment  for  which  will 
be  described  later,  but  if  such  be  not  found  it  is  essential  that 
the  base  of  the  growth  be  destroyed.  Chromic  acid  is  pref- 
erable for  this  purpose,  although  nitrate  of  silver  has  been 
employed  to  some  extent,  and  with  the  acid  fused  on  a  probe 
after  the  tissues  have  been  thoroughly  dried  the  remnants 
of  the  growth  are  entirely  destroyed,  care  being  taken  that 
the  cauterant  is  not  too  lightly  applied,  so  that  the  parts  are 
only  stimulated  to  further  growth,  and  if  the  base  of  the 


Operations  through  External  Auditory  Canal.     161 

growth  be  very  small  and  soft,  the  destruction  is  easily 
accomplished  by  a  superficial  application,  but  if  it  be  firm 
and  large,  it  is  necessary  that  it  be  thoroughly  burnt  away, 
often  several  applications  at  intervals  of  from  one  day  to 
a  week  being  necessary  to  accomplish  this  purpose.  After 
the  base  of  the  growth  has  been  cauterized  in  this  manner,  it 
may  be  lightly  dusted  with  an  antiseptic  iodine  powder,  or 
what  has  proven  more  preferable  in  some  cases,  one  of  the 
various  nonirritating  silver  salts  may  be  used  in  diluted  solu- 
tion every  day  or  less  frequently,  as  may  be  required  in  the 
particular  case,  any  tendency  to  the  recurrence  of  the  growth 
being  at  once  controlled  by  cauterization.  No  one  treatment 
is  applicable  to  these  cases  and  even  in  the  same  case  it  is 
often  essential  to  vary  the  medication  from  time  to  time. 
One  may  also  use  a  i :  500  or  even  stronger  solution  of  for- 
maline, directly  applied  to  the  area  of  the  growth  with  the 
cotton  tuft.  In  addition  to  the  powerful  antiseptic  influence 
of  the  formaline,  it  also  markedly  constricts  the  growth. 

When  large  masses  of  granulation  tissue  have  been  cu- 
retted away  or  the  hypertrophied  mucous  membrane  removed 
by  the  same  means  and  the  parts  have  been  cleansed,  the 
middle  ear  may  be  dusted  with  iodoform  or  any  of  the  anti- 
septic powders  mentioned  and  drained  by  gauze  or  not,  as 
may  seem  most  satisfactory.  In  many  of  these  cases,  espe- 
cially if  carious  bone  be  present,  there  is  a  constant  ten- 
dency towards  the  redevelopment  of  exuberant  granulation 
tissue  probably  for  some  months  after  operation.  This  con- 
dition is  more  in  evidence  if  various  partly  inaccessible  niches 
of  diseased  tissue  in  the  tympanic  walls  have  been  left  un- 
touched. For  the  purpose  of  lessening  the  secretion  and 
producing  a  more  healthy  lining  for  the  tympanum,  the  judi- 
cious application  of  95  per  cent,  alcohol  is  very  beneficial; 
it  should  be  applied  by  lightly  mopping  the  remnants  of  the 
altered  mucosa  once  or  twice  weekly  and  between  these  appli- 

12 


1 62  Suppuration  of  the  Middle  Ear. 

cations  the  dry  dressings  should  be  daily  employed  if  pos- 
sible, but  if  not,  when  the  discharge  is  profuse  it  will  be 
necessary  to  syringe  the  ear  in  order  to  remove  the  exces- 
sive secretion.  Before  the  application  of  any  of  these  local 
measures  directly  to  the  mucous  membrane,  it  is  very  essen- 
tial that  the  parts  be  cleansed  of  mucus  or  purulent  secre- 
tion, so  that  the  applications  may  directly  influence  the  parts 
to  which  they  are  applied,  and  when  the  application  is  made 
to  a  limited  area  where  it  is  desired  that  its  effects  be  con- 
fined, these  tissues  should  be  always  dried  after  cleans- 
ing. In  the  after  treatment  of  the  removal  of  granulation 
tissue,  all  new  growths  which  are  excessive  in  development, 
or  which  project  above  the  surface,  so  that  folds  and  crev- 
ices are  found  which  may  retain  infective  secretion,  must  be 
destroyed  by  the  various  methods  outlined,  the  objects  to  be 
attained  here,  as  also  after  removal  of  the  carious  ossicles, 
being  to  produce  a  smooth,  nonsecreting  surface  to  replace 
the  pus-forming  pathological  tissue  which  has  in  part  been 
removed.  Carbolic  acid  in  glycerine  or  water  in  strength 
of  from  i  to  10-25  is  very  useful  for  this  purpose  in  cases 
where  the  secretion  is  somewhat  profuse.  When  used  in 
the  weaker  solutions  it  may  be  instilled  into  the  ear,  and 
allowed  to  remain  a  few  moments,  when  it  is  removed  with 
the  cotton  tuft  on  an  applicator,  or  if  the  stronger  solutions 
be  employed,  the  parts  should  be  lightly  brushed  over  with 
the  drug,  which  is  allowed  to  remain  for  a  greater  or  lesser 
time  as  the  conditions  may  seem  to  demand,  and  it  is  then 
removed  or  not  as  may  seem  must  suitable. 

A  favorite  mode  of  healing  the  curetted  surfaces,  and 
one  which  will  produce  excellent  results  in  many  cases,  is 
a  strong  solution  of  boracic  acid  in  water,  or  even  more 
preferable,  is  the  use  of  a  saturated  solution  of  this  agent  in 
absolute  alcohol.  This  is  applied  to  the  parts  desired  in  the 
manner  already  described,  and  it  exercises  a  most  beneficial 


Operations  through  External  Auditory  Canal.    163 

effect  in  those  cases  where  the  secretion  is  not  excessive  by 
markedly  drying  the  tissues,  diminishing  the  discharge  and 
actively  restraining  the  growth  of  excessive  granulation  tis- 
sue, its  application  being  repeated  several  times  daily  or  less 
often,  dependent  upon  the  effects  obtained.  Some  otologists, 
after  curetting  the  granulating  and  hyperplastic  mucous 
membrane,  prefer  to  cauterize  the  entire  raw  surface  with 
nitrate  of  silver  or  chloride  of  zinc  solutions.  This  treat- 
ment at  first  produces  an  excessive  mucopurulent  secretion, 
but  it  is  claimed  that  better  results  are  obtained  in  this 
manner  than  by  other  methods,  and  in  Bonain's  cases  treated 
in  this  manner,  which  were  dressed  with  iodoform  gauze 
packing  changed  twice  daily,  the  discharge  ceased  promptly 
and  but  twenty-one  days  were  required  as  an  average  to 
obtain  a  cure.  The  reactive  inflammation  that  sometimes 
takes  place  after  this  extensive  cauterization  is,  however,  a 
serious  drawback,  and  although  excellent  results  are  ob- 
tained at  times  by  this  method,  as  a  rule  one  will  obtain  as 
good  results  without  the  dangers  if  the  various  methods  as 
given  here  be  employed. 

The  use  of  the  syringe  for  removing  the  debris  and  puru- 
lent secretion  from  the  ear  after  any  of  these  operations 
should  be  guided  entirely  by  the  width  of  the  external  canal 
and  the  amount  of  the  purulent  discharge.  With  a  broad, 
wide  canal  where  there  is  no  obstruction  to  the  return  flow 
of  the  solution  employed,  syringing  is  not  contraindicated. 
When  the  secretion  is  thick  and  inspissated  and  is  retained 
in  localities  in  the  tympanic  cavity  where  it  is  impossible  to 
remove  it  with  the  applicator,  the  use  of  an  antiseptic  solu- 
tion with  which  the  pus  is  dislodged  by  syringing  is  essential 
after  any  of  these  operative  procedures,  as  it  is  the  only 
means  which  presents  a  minimum  of  danger  by  which  the 
parts  can  be  rendered  at  all  clean.  Filling  the  ear  with  per- 
oxide of  hydrogen,  either  before  or  after  operations  through 


1 64  Suppuration  of  the  Middle  Ear. 

the  canal,  is  to  be  deprecated,  as  it  not  only  serves  to  dissem- 
inate the  pus  and  infect  new  areas,  but  also  when  erroneously 
employed  in  this  manner  plays  a  prominent  role  in  the  pro- 
duction of  mastoid  infection,  and  further,  when  used  in  the 
syringe  for  cleansing  the  suppurating  ear  or  to  aid  in  the 
removal  of  some  particle  of  cheesy  pus  or  broken  down 
epithelial  tissue  after  operation  it  is  always  sure  to  do  harm 
and  defeat  the  objects  for  which  the  operation  was  per- 
formed. When  partially  inaccessible  portions  of  the  lower 
tympanic  space,  and  especially  the  attic,  require  syringing, 
one  must  employ  delicate  curved  cannulas  which  will  reach 
the  parts  and  be  of  sufficient  caliber  to  allow  a  stream  of  the 
solution  employed  to  be  of  use  in  dislodging  the  retained 
secretion,  while  at  the  same  time  it  is  essential  that  the 
syringe  and  cannulus  should  be  so  constructed  that  they  may 
readily  be  rendered  aseptic.  Care  should  also  be  taken  in 
keeping  the  large  aural  syringe  surgically  clean  when  used 
for  washing  out  the  external  and  lower  tympanic  space. 
Syringing  may  also  be  indicated  if  there  be  much  pain  after 
operation,  irrespective  of  the  amount  of  discharge,  when  the 
dressings  should  be  removed  and  any  retained  secretion  or 
blood  clots  causing  distress  to  the  patient  should  be  removed 
in  this  manner. 

When  the  discharge  is  scanty,  or  if  more  profuse  but 
readily  removed  with  cotton  tufts  on  the  applicator,  it  will 
generally  be  found  that  the  ear  should  not  be  syringed ;  better 
results,  as  regards  the  more  prompt  subsidence  of  the  dis- 
charge and  the  healing  of  the  parts,  being  obtained  when 
up  to  a  certain  indefinite  limit  the  tissues  are  maintained  as 
free  from  the  presence  of  solutions  introduced  through  the 
canal  as  possible.  This  is  especially  applicable  in  those  cases 
where  the  diseased  area  is  limited  and  drainage  is  free. 
With  some  cases,  where  the  discharge  is  exceedingly  pro- 
fuse, it  may  be  essential  at  first  to  syringe  the  ear  two  or 


Operations  through  External  Auditory  Canal.     165 

more  times  daily  in  order  to  remove  at  all  the  rapidly  accu- 
mulating purulent  secretion,  but  as  a  rule  these  cases  are 
the  exception,  and  syringing  the  ear  once  daily,  when  it  is 
indicated,  will  be  sufficient  in  the  majority  of  cases.  The 
time  between  the  syringing  being  determined  by  the  amount 
of  pus  present,  it  being  the  object  to  cease  cleansing  the  ear 
in  this  way  as  soon  as  possible,  for  if  long  continued  it 
produces  a  marked  tendency  towards  macerating  the  tissues 
both  of  the  canal  and  middle  ear,  with  the  further  develop- 
ment of  exuberant  granulation  tissue.  Various  solutions 
may  be  used  for  this  purpose,  depending  upon  the  selection 
of  the  operator  and  the  results  to  be  obtained,  but  they  should 
all  be  nonirritating  and  sterile.  Warm  physiological  salt 
solution  is  probably  the  most  preferable  and  harmless  for 
purely  cleansing  purposes.  Solutions  of  boric  acid,  bichlo- 
ride of  mercury  1 : 5000-10000,  carbolic  acid  1 : 100-500,  and 
formaline,  the  latter  very  much  diluted,  are  frequently  em- 
ployed with  good  advantage. 

The  after  treatment  of  cholesteatoma,  when  removed 
through  the  canal,  does  not  differ  in  any  essential  respects 
from  the  treatment  instituted  when  the  ossicles  have  been 
removed  and  the  tympanic  walls  curetted,  as  the  presence  of 
these  epithelial  masses  seem  to  constitute  an  essential  part 
of  the  process  when  it  is  extensive.  It  is  necessary,  however, 
to  carefully  watch  such  cases  where  large  quantities  of  these 
epithelial  masses  have  been  removed  for  a  much  longer 
period  after  the  suppuration  has  ceased  than  would  be  the 
case  if  they  had  not  been  present,  and  should  there  be  a 
tendency  towards  the  excessive  proliferation  of  epithelial 
structures,  such  areas  where  this  takes  place  should  be  cu- 
retted away  as  often  as  necessary,  or  if  the  tendency  to 
recurrence  is  so  great  that  this  seems  of  no  service,  then  a 
post-auricular  radical  operation  must  be  performed. 

When  the  malleus  and  incus  have  been  removed  and  the 


1 66  Suppuration  of  the  Middle  Ear. 

tympanum  cleansed  and  as  far  as  possible  dried,  it  is  always 
well  for  the  first  day  at  least  to  place  a  gauze  drain  in  the 
canal  and  occlude  the  external  meatus  with  absorbent  cotton, 
the  latter  being  replaced  if  it  should  become  stained  with  the 
discharges.  After  the  first  twenty-four  hours  the  treatment 
must  vary  in  each  case,  and  practically  consists  in  treating 
the  suppurative  otitis  as  before  operation  in  the  great  ma- 
jority of  cases,  excepting  that  the  facilities  for  local  medi- 
cation have  been  greatly  improved  by  the  removal  of  the 
obstruction  to  the  treatment  of  hitherto  inaccessible  portions 
of  the  tympanic  cavity.  As  in  a  general  way  the  after  treat- 
ment differs  in  no  respects  from  the  treatment  of  chronic  sup- 
purative otitis  media,  it  will  not  be  described  in  any  detail 
here,  it  being  desired  to  emphasize  only  those  points  of  the 
treatment  more  or  less  closely  associated  with  the  operative 
treatment  of  this  affection.  After  the  first  day,  if  there  are 
no  indications  for  removing  the  dressings  previous  to  this, 
the  canal  and  tympanum  should  be  thoroughly  cleansed  as 
described  and  the  tissues  mopped  with  a  I  to  1000  or  I  to 
2000  formaline  solution  and  a  free  drain  inserted  or  not  as 
may  seem  most  advisable.  Should  the  discharge  rapidly 
lessen  in  amount,  it  is  not  essential  to  dress  the  ear  daily, 
but  every  other  day  will  often  be  sufficient.  Where  the  for- 
maline proves  too  irritating,  causing  considerable  pain,  or 
later  the  parts  do  not  improve  as  they  should  under  its  use,  it 
should  be  discontinued  and  another  remedy  employed,  such 
as  an  alcoholic  solution  of  boric  acid  or  one  of  the  nonirri- 
tating  silver  salts,  as  previously  mentioned.  Each  time  the 
ear  is  cleansed  and  medicated,  as  it  were,  at  least  for  the 
first  one  or  two  weeks,  the  plain  or  iodoform  gauze  drain 
should  be  inserted  until  the  marked  lessening  of  the  discharge 
no  longer  warrants  it,  when  careful  cleansing  followed  by 
a  dusting  powder,  will  be  all  that  is  required.  Absolute 
alcohol  may  occasionally  be  indicated  to  shrink  a  small  recur- 


Operations  through  External  Auditory  Canal.     167 

ring  patch  of  granulation  tissue  or  hyperplastic  mucosa,  and 
one  will  find  it  very  efficient  for  this  purpose. 

In  using  the  gauze  drain  after  ossiculectomy,  it  should 
not  closely  fill  the  canal,  but  should  be  rather  loosely  packed 
in  it,  and  should  reach  from  well  into  the  tympanic  cavity 
out  into  the  external  meatus,  where  it  drains  if  the  discharge 
be  very  profuse  into  a  fairly  large  pad  of  absorbent  cotton, 
entirely  filling  the  concha,  and  retained  in  place  with  a  small 
strip  of  adhesive  plaster.  When  there  are  any  doubts  as  to 
the  patient  interfering  with  the  inner  gauze  drain,  it  is  well 
to  use  two  pieces  for  this  purpose,  one  being  placed  in  the 
deeper  parts  of  the  canal,  and  after  this  is  in  position,  another 
strip  of  gauze  is  inserted  against  the  former,  so  if  by  acci- 
dent or  otherwise  the  dressings  are  disturbed,  the  tympanic 
cavity  will  still  remain  protected,  this  method  of  dressing 
the  ear  being  of  special  value  in  restless  children.  When  it 
is  impracticable  to  see  the  case  more  than  once  a  day  and 
the  discharge  is  profuse,  the  patient  should  be  instructed  to 
remove  the  cotton  in  the  meatus  only  and  replace  it  with  a 
fresh  piece  should  it  become  saturated,  but  under  no  circum- 
stances should  the  patient  in  any  way  interfere  with  the 
deeper  dressings  at  any  time,  as  long  as  it  is  necessary  to 
employ  this  method  of  dressing.  In  cleansing  the  tympanic 
cavity,  and  especially  the  attic,  after  it  has  been  eviscerated, 
it  is  best  to  employ  a  bent  flexible  applicator  which  when 
wrapped  with  cotton  will  reach  all  the  nooks  and  crannies 
and  allow  of  the  thorough  removal  of  irritating  secretion 
even  well  into  the  aditus,  and  after  this  thorough  cleansing 
the  necessary  medicaments  may  be  employed  in  solution  or 
as  powder  as  may  be  desired.  In  all  cases  after  ossiculec- 
tomy, the  patient  must  not  treat  the  ear  himself  in  any  way, 
other  than  to  change  the  external  dressing,  as  already  men- 
tioned, and  in  a  few  cases  it  will  be  best  for  the  otologist  or 
a  competent  assistant  to  dress  the  ear  twice  daily  for  the  first 


1 68  Suppuration  of  the  Middle  Ear. 

week  or  so,  then  the  local  treatment  is  carried  out  as  often 
as  may  be  necessary  in  the  individual  case,  the  time  that  the 
discharge  takes  to  reform  indicating  the  necessary  duration 
between  the  applications  to  the  tympanum.  Even  in  cases 
where  but  little  after  treatment  is  required  and  the  purulent 
secretion  promptly  ceases,  the  tympanum  should  be  examined 
at  intervals  for  several  months,  so  that  any  evidence  of  an 
early  return  of  the  suppuration  may  be  quickly  controlled. 
In  many  of  these  cases  after  ossiculectomy,  the  condition  as 
regards  the  local  infection  is  after  a  longer  or  shorter  time 
permanently  cured,  but  in  others,  although  the  patient  may 
consider  himself  well,  yet  a  slight  moisture  is  present  in  the 
fundus  of  the  canal,  which  may  show  itself  from  time  to 
time  as  a  slight  drying  of  the  secretion  into  a  scab,  and  as 
long  as  this  continues  the  patient  should  remain  under  treat- 
ment. 

In  those  cases  where  there  is  but  a  slight  serous  or  semi- 
purulent  discharge,  the  use  of  moisture  in  the  middle  ear 
must  be  carefully  avoided,  and  if  necessary  to  obtain  clean- 
liness the  parts  should  be  thoroughly  dried  and  lightly  dusted 
over  with  an  antiseptic  powder,  boracic  acid  in  impalpable 
powder  being  usually  preferred  when  the  conditions  are  as 
just  described  and  when  there  is  no  great  tendency  to  the 
excessive  proliferation  of  granulation  tissue,  while  when  the 
latter  phenomenon  is  marked,  an  iodine  powder  seems  to  give 
better  results  in  restraining  the  growth.  Where  the  tissues 
are  apparently  sluggish  and  resolution  seems  delayed,  while 
the  purulent  discharge,  while  not  profuse,  is  yet  more  copious 
than  the  conditions  present  would  seem  to  warrant,  a  solution 
of  one  part  of  carbolic  acid  in  twenty-five  parts  of  glycerine, 
applied  by  the  applicator  once  daily  or  two  or  three  times  a 
week  as  may  seem  most  suitable  in  the  individual  case,  will 
often  markedly  restore  the  tonus  to  the  involved  mucosa 
within  a  short  time  and  produce  a  rapid  amelioration  in  the 
amount  of  the  discharge. 


Operations  through  External  Auditory  Canal.     169 

While  it  was  stated  in  the  chapter  on  the  preparation  of 
the  patient  for  operation  that  the  upper  respiratory  tract 
should  be  placed  in  as  normal  a  condition  as  possible  before 
operation,  it  is  also  desired  to  emphasize  in  this  place,  that 
as  part  of  the  after  treatment  of  the  tympanic  cavity,  careful 
attention  should  be  paid  to  the  nose,  and  especially  to  the 
nasopharynx.  Where,  for  various  reasons,  this  has  been 
impossible  previous  to  the  aural  operation,  any  abnormalities 
which  have  a  bearing  upon  the  latter  affection  should  be  cor- 
rected, and  while  it  is  not  advisable  as  a  rule  to  operate  in 
this  region  for  a  week  or  two  after  an  ossiculectomy,  yet 
such  should  be  done  as  soon  as  the  middle  ear  irritation  has 
subsided.  The  main  point,  however,  in  this  respect,  is  the 
careful  cleansing  of  the  nares  and  nasopharynx,  so  that  in- 
fection through  the  Eustachian  tube  is  reduced  to  a  minimum 
and  congestion  in  this  region  lessened  as  far  as  possible. 
The  influence  of  such  care  of  the  nasopharynx  especially  is 
well  demonstrated  in  those  cases  where  the  ear  continues  to 
suppurate  despite  the  fact  that  the  ossicles  have  been  excised, 
the  mucosa  curetted  and  the  carious  osseous  tissue  has  been 
removed  from  the  walls  and  careful  after  treatment  has  been 
faithfully  carried  out,  yet  within  a  short  time  after  a  small 
mass  of  adenoid  tissue  has  been  removed  from  the  vault  of 
the  pharynx  or  from  its  lateral  walls  in  the  vicinity  of  the 
Eustachian  tube,  the  purulent  secretion  from  the  tympanic 
cavity  ceases,  and  as  long  as  the  upper  respiratory  tract 
remains  in  normal  condition,  so  long  does  the  ear  remain 
perfectly  dry.  While  it  is  always  needful  that  care  be  given 
to  the  nose  and  pharynx,  those  cases  in  which  the  purulent 
discharge  from  the  middle  ear  is  mixed  with  mucus  from 
the  Eustachian  tube  should  receive  most  careful  attention, 
and  in  addition  to  the  proper  treatment  directed  to  the  middle 
ear,  nose  and  nasopharynx,  it  is  also  essential  that  the  tube 
should  be  carefully  looked  after,  or  any  operative  procedure 
will  undoubtedly  fail  to  be  of  full  benefit  to  the  patient. 


1 70  Suppuration  of  the  Middle  Ear. 

When  a  small  area  of  carious  bone  has  been  removed 
from  the  tympanum,  either  on  its  inner  promontory  wall  or 
from  the  margo  tympanicus,  without  the  removal  of  the 
ossicles,  the  treatment  after  operation  will  differ  in  no  way 
from  that  described  when  an  ossiculectomy  has  been  per- 
formed, excepting  that  one  must  carefully  examine  the  case 
for  a  longer  or  shorter  period  in  order  that  active  measures 
may  be  instituted  if  the  carious  area  does  not  promptly  heal, 
or  if  it  again  recurs.  As  a  rule,  the  majority  of  such  cases 
heal  promptly  and  more  thoroughly  when  the  affected  areas 
are  dusted  daily,  until  healing  is  completed,  with  an  iodine 
powder,  and  as  far  as  the  case  will  admit  this  dry  method 
of  treatment  should  be  strictly  adhered  to.  lodoform,  or 
several  of  the  various  antiseptic  drying  powders  of  a  simi- 
lar nature,  seem  to  possess  peculiar  properties  of  value  in 
these  carious  cases,  and  in  appropriate  instances,  if  they  are 
intelligently  employed,  they  produce  a  more  or  less  rapid 
decrease  in  the  amount  of  purulent  discharge  and  act  as  val- 
uable stimulants  to  the  formation  of  healthy  granulation 
tissue. 

If  in  addition  to  an  ossiculectomy,  the  osseous  walls  of 
the  tympanic  cavity  have  been  curetted,  a  somewhat  different 
line  of  treatment  must  be  adopted,  inasmuch  as  the  patient 
for  a  time  at  least  must  be  under  observation  more  closely 
than  when  the  other  operations  through  the  canal  have  been 
performed,  on  account  of  the  more  serious  nature  and  extent 
of  this  procedure.  Immediately  after  operation  and  when 
the  bleeding  has  been  controlled,  the  ear  should  be  thor- 
oughly syringed  with  any  of  the  cleansing  solutions  pre- 
viously noted  and  then  carefully  examined  to  remove  any 
minute  particles  of  bone  which  may  have  been  left,  or  any 
carious  tissue  not  previously  removed,  and  which  may  have 
been  overlooked.  The  walls  of  the  tympanic  cavity  may 
then  be  carefully  mopped  with  a  full  strength  solution  of 


Operations  through  External  Auditory  Canal.     171 

peroxide  of  hydrogen  on  cotton  pledgets,  in  order  to  get  rid 
of  any  pus  which  may  still  remain  and  this  is  also  efficient 
in  controlling  any  slight  venous  oozing  still  present.  Or 
the  tympanum  may  be  cleansed  with  a  I  to  20  solution  of 
carbolic  acid  added  to  a  I  to  500  bichloride  of  mercury  solu- 
tion, which  is  very  efficient  for  this  purpose  where  bone 
lesions  are  present,  but  care  must  be  observed  that  these  anti- 
septics be  not  used  in  excess  and  especially  that  none  of  the 
solution  is  allowed  to  escape  through  the  Eustachian  tube 
into  the  pharynx  or  is  retained  in  the  tympanic  cavity,  for 
fear  of  its  absorption  and  the  production  of  toxic  symptoms. 
After  the  parts  have  been  cleansed  by  any  of  these  methods, 
iodoform  or  a  similar  powder  should  be  well  dusted  over  the 
tissues  and  an  iodoform  gauze  drain  inserted  in  the  canal. 
This  may  be  left  for  forty-eight  hours  without  disturbing 
it  if  the  discharge  be  not  excessive,  but  as  a  rule  the  patient 
is  more  comfortable  if  the  dressings  be  changed  in  twenty- 
four  hours,  as  usually  the  discharge  is  very  profuse  for  a 
short  time  following  operation.  During  the  course  of  the 
after  treatment,  the  tendency  for  the  development  of  granu- 
lation tissue  over  the  exposed  bone  areas  is  very  marked, 
and  this  must  be  controlled  by  any  of  the  ways  previously 
described,  if  necessary  the  curette  being  employed  from  time 
to  time.  It  may  also  be  essential  to  curette  small  areas  of 
bone  which  may  at  this  time  lose  their  vitality,  or  a  most 
excellent  plan  for  this  purpose,  especially  when  the  bone  is 
actually  carious,  is  to  use  pure  lactic  acid  on  a  cotton-tipped 
applicator  and  rub  it  thoroughly  into  the  tissues  desired. 
This  may  be  employed  as  often  as  may  seem  necessary,  but 
a  week  or  ten  days  should  intervene  between  the  applica- 
tions and  in  not  a  few  of  the  cases  where  it  is  indicated  the 
beneficial  results  are  shown  by  the  development  of  healthy 
granulation  tissue  over  the  previously  denuded  bone  surface, 
with  later  complete  cicatrization. 


172  Suppuration  of  the  Middle  Ear. 

In  those  cases  where  osseous  lesions  are  present  and  the 
tympanic  cavity  is  markedly  septic,  the  following  treatment 
has  been  recommended  and  will  frequently  be  of  considerable 
aid  in  these  most  troublesome  cases.  It  is  carried  out  by 
packing  the  canal  well  into  the  tympanum  with  gauze  strips 
moistened  with  a  i  to  20  carbolic  acid  solution  and  then  the 
end  of  the  gauze  in  contact  with  the  tympanic  cavity  is  well 
covered  with  a  mixture  of  iodoform  and  carbolic  acid  solu- 
tion of  the  same  strength,  so  that  a  paste  is  formed.  This 
dressing  is  allowed  to  remain  in  the  ear  for  a  day  following 
the  operation  and  is  then  changed  every  one  or  two  days 
or  less  frequently  as  may  be  necessary,  a  valuable  guide  as 
to  when  the  dressings  shall  be  changed  being  shown  by  the 
end  of  the  gauze  becoming  saturated  with  the  discharge, 
when  it  should  be  removed  and  a  fresh  dressing  inserted. 
At  each  dressing  the  ear  should  be  thoroughly  cleansed  by 
any  of  the  methods  previously  advised  and  any  excessive 
granulation  tissue  or  suspicious  bone  areas  should  receive 
proper  attention.  For  cleansing  purposes  with  this  form  of 
dressing  the  ear  may  be  syringed  with  a  I  to  40  carbolic 
acid  solution  and  if  there  be  any  odor  present,  which  is  very 
apt  to  be  noticed  for  a  time,  the  tissues  are  dusted  with  iodo- 
form powder.  As  a  result  of  this  treatment,  in  many  cases 
excellent  results  are  obtained,  especially  when  the  ossicles 
have  been  removed  and  the  walls  curetted,  in  some  few  cases 
where  the  involvement  of  the  tympanic  walls  has  been  slight, 
the  discharge  will  permanently  cease  within  a  few  days  after 
operation,  while  in  other  cases  the  treatment  undoubtedly  to 
a  marked  degree  shortens  the  course  of  the  purulent  process. 

Whenever  gauze  drainage  is  employed  after  these  opera- 
tions, several  factors  must  be  kept  in  mind.  The  object  of 
the  drain  is  to  draw  the  purulent  secretion  from  the  tympanic 
cavity  and  not  as  an  occlusive  dressing,  which  function  is 
taken  by  the  cotton  pledget  placed  in  the  meatus.  It  is  essen- 


Operations  through  External  Auditory  Canal.     173 

tial  that  when  moistened  with  any  antiseptic  solution  that 
the  excess  of  the  liquid  be  removed  before  the  gauze  is 
inserted  into  the  canal,  for  if  this  is  not  done,  its  functions 
as  a  drain  will  be  considerably  lessened  and  the  object  for 
which  it  was  placed  in  the  canal  will  be  to  a  great  extent 
defeated.  Furthermore,  as  there  is  nearly  always  some 
slight  vascular  oozing  following  curettage,  if  the  gauze  does 
not  stop  this  when  it  is  packed  well  into  the  tympanic  cavity 
or  carry  the  excess  of  secretion  away,  retention  with  the 
formation  of  a  large  blood  clot  takes  place  and  the  patient 
will  suffer  considerable  pain  unless  the  dressings  be  speedily 
removed.  To  guard  against  retention,  it  is  the  most  ser- 
viceable plan  to  simply  lay  a  small  strip  of  gauze  along  the 
floor  of  the  canal  and  if  firmer  packing  be  considered  nec- 
essary, it  may  be  confined  solely  to  the  tympanic  cavity.  As 
a  rule,  however,  in  the  large  majority  of  cases  where  it  is 
desired  to  use  a  gauze  drain,  packing  is  entirely  unnecessary 
and  free  exit  should  be  maintained  in  every  way  for  the  dis- 
charge of  the  pus.  Plain  sterilized,  iodoform  or  borated 
gauze  is  most  frequently  employed  for  this  purpose,  and  in 
bone  cases  iodoform  gauze  is  usually  to  be  preferred,  while 
in  those  cases  where  the  osseous  walls  are  not  involved,  it 
is  more  satisfactory  to  use  the  sterile  gauze  alone.  Both 
bichloride  and  iodoform  gauze  will  occasionally  irritate  the 
dermal  lining  of  the  canal,  especially  in  children  and  young 
adults,  and  when  such  is  the  case  the  other  varieties  of  gauze 
must  be  substituted,  or  some  other  of  the  various  iodine- 
bearing  antiseptic  powders  may  be  rubbed  into  the  meshes 
of  the  gauze  and  an  efficient  substitute  thus  will  be  obtained. 
Pain  in  some  few  individuals  may  necessitate  some  atten- 
tion for  a  few  days  after  ossiculectomy  and  curettement.  It 
may  be  the  result  of  two  causes,  one  which  has  been  men- 
tioned, that  is,  retention  of  blood  clots  or  pus  as  a  result  of 
improper  application  of  the  dressings,  and  which  is  readily 


174  Suppuration  of  the  Middle  Ear. 

relieved  by  their  temporary  removal,  while  in  not  a  few  ner- 
vous individuals  considerable  pain  or  distress  may  be  com- 
plained of  from  the  traumatism  to  which  the  tympanic  cavity 
has  been  subjected.  The  mere  cleansing  of  the  ear  in  itself 
will  often  be  sufficient  to  remedy  this  annoyance,  while  in 
other  cases,  where  it  is  more  or  less  persistent,  lightly  dust- 
ing the  tissues  with  orthoform  powder  will  benumb  the  ex- 
posed nerve  endings  and  often  give  complete  relief.  At  the 
most,  the  pain  only  persists  for  a  few  days  after  the  opera- 
tion and  then  ceases  spontaneously,  but  if  it  should  persist 
for  a  week  or  more,  one  is  warranted  in  believing  that  new 
areas  have  been  infected  and  that  an  acute  inflammation  is 
present,  or  that  there  is  a  small  pocket  of  retained  purulent 
secretion  which  should  be  located  and  treated  accordingly, 
this  being  especially  so  when  other  symptoms,  as  a  marked 
rise  in  temperature,  are  also  present. 

If  some  of  the  minor  operations  through  the  canal  have 
been  performed  and  the  patient  is  in  good  physical  condition, 
it  is  not  necessary  that  any  special  attention  be  paid  to  his 
general  health,  but  when  ossiculectomy  has  been  performed, 
and  especially  when  the  tympanic  walls  have  been  curetted, 
general  constitutional  treatment  is  frequently  absolutely 
essential.  In  children  and  young  adults  the  syrup  of  the 
iodide  of  iron  seems  to  be  very  valuable,  but  the  treatment 
used  in  any  case,  as  far  as  the  general  health  is  concerned, 
must  depend  entirely  upon  the  conditions  present. 

After  the  minor  operations  through  the  external  canal, 
such  as  enlarging  a  perforation  or  making  a  second  perfora- 
tion in  the  membrana  tympani,  it  is  not  necessary  that  the 
patient  should  be  kept  under  any  especial  care  during  the 
first  day  following  operation,  but  when  an  ossiculectomy  has 
been  performed  or  the  walls  of  the  cavum  tympani  curetted, 
it  is  best  that  the  patient  be  kept  in  bed  for  several  days  fol- 
lowing the  operation.  As  a  rule  the  patient  should  be  kept 


Operations  through  External  Auditory  Canal.     175 

away  from  his  occupation  for  a  week  following  such  opera- 
tions and  for  the  first  day  or  two  he  should  be  kept  in  bed, 
the  recumbent  position  favoring  drainage  from  the  ear  oper- 
ated upon.  When  the  inflammatory  symptoms  become  prom- 
inent, following  this  operation,  it  is  advisable  that  the  patient 
remain  in  bed  or  in  a  recumbent  position  until  the  tempera- 
ture returns  to  the  normal,  but  in  a  not  inconsiderable 
number  of  these  cases  no  ill  effects  at  all  follow  operation, 
and  while  the  patient  in  such  cases  should  not  be  confined 
to  bed,  yet  it  is  better  that  he  should  avoid  any  fatigue  or 
excitement  during  the  first  week  after  operation.  It  is  also 
advisable  after  such  operations  that  the  diet  should  be  re- 
stricted as  far  as  possible,  and  while  it  may  not  seem  to 
concern  the  aural  affection,  yet  as  a  rule  it  is  always  advis- 
able to  keep  the  bowels  open  in  such  cases  as  a  part  of  the 
routine  after  treatment. 

The  length  of  time  before  the  purulent  discharge  ceases 
depends  entirely  upon  the  extent  of  the  morbid  process  in 
the  tympanic  cavity  and  the  thoroughness  with  which  the 
affected  tissues  are  removed.  In  minor  cases,  where  the 
lesions  are  but  slight,  the  discharge  usually  ceases  imme- 
diately or  at  the  most  a  few  days  after  operation,  but  in  those 
cases  where  the  ossicles  have  been  removed  and  the  osseous 
walls  curetted,  the  duration  of  the  discharge  will  depend  upon 
the  complications  which  arise,  the  resistance  of  the  tissues 
and  the  virulency  of  the  middle  ear  infection.  In  those  cases 
where  the  osseous  lesions  are  not  prominent,  the  discharge, 
as  a  rule,  ceases  in  from  one  to  two  months  after  operation, 
but  in  cases  where  the  tympanic  walls  are  involved  to  any 
considerable  extent,  it  may  take  a  much  longer  period  before 
the  suppuration  has  entirely  disappeared.  In  those  cases  in 
which  successful  results  are.  obtained,  usually  after  a  long 
period  of  after  treatment,  the  tympanic  mucosa  assumes  a 
dermoid  appearance  and  its  functions  as  a  mucous  membrane 


176  Suppuration  of  the  Middle  Ear. 

are  gone.  This  desirable  result,  which  is  always  to  be 
looked  for  in  those  cases  in  which  the  suppuration  has  ceased, 
may  be  enhanced  by  allowing  the  small  segment  of  mem- 
brana  tympani  to  remain  after  excision  which  is  situated  at 
the  lower  segment  of  the  annulus  tympanicus,  as  in  this  posi- 
tion it  will  usually  become  attached  to  the  promontory  wall 
which  is  situated  directly  opposite  to  it  and  growing  here, 
the  epithelial  surface  will  form  a  nidus  from  which  the  walls 
of  the  tympanic  cavity  will  gradually  undergo  a  dermoid 
transformation  and  a  nonsecreting  surface  will  line  the  tym- 
panic cavity,  so  that  as  long  as  this  remains  intact  the  patient 
will  no  longer  be  subject  to  discharge  from  the  middle  ear, 
and  in  all  cases  of  chronic  suppuration  where  it  is  necessary 
to  eviscerate  the  tympanic  cavity,  this  should  be  the  object 
to  be  attained. 


PART  II. 

OPERATIONS  UPON  THE 
MASTOID  PROCESS. 


13  177 


CHAPTER  I. 

ANATOMICAL  AND  SURGICAL 
LANDMARKS. 


'79 


ANATOMICAL  AND  SURGICAL  LANDMARKS. 

As  in  many  cases  of  chronic  suppurative  otitis  media 
which  seek  operative  measures  for  the  relief  of  the  puru- 
lent discharge,  the  morbid  process  is  no  longer  confined  to 
the  tympanic  cavity,  including  the  attic,  but  has  extended 
through  the  aditus  and  antrum  to  the  mastoid  cells,  it  is 
essential  that  the  entire  diseased  area  be  obliterated  to  obtain 
a  successful  result.  The  mastoid  operation  or  any  of  its 
various  modifications  may  be  necessitated  for  acute  inflam- 
mation of  this  region,  for  the  relief  of  tympanic  complica- 
tions either  intracranial  or  not,  for  the  acute  exacerbations 
of  a  chronic  inflammation  which  has  previously  remained 
quiescent,  or  it  may  be  performed  both  as  a  preventative  of 
serious  mischief  from  the  aural  lesion  and  directly  for  the 
relief  of  the  chronic  suppuration  in  which  the  various  opera- 
tive procedures  described  in  the  previous  chapters  have  failed 
to  produce  the  expected  relief,  or  in  which  operation  through 
the  external  auditory  canal  is  contraindicated  by  symptoms 
suggestive  of  an  extension  of  the  lesions  which  cannot  be 
eliminated  by  the  lesser  surgical  procedures.  It  is  the 
latter  with  which  we  are  here  concerned,  that  is,  the  oper- 

181 


1 82  Suppuration  of  the  Middle  Ear. 

ative  treatment  through  the  post-auricular  route  for  the 
amelioration  or  cure  of  the  chronic  suppurative  otitis  media. 
As  the  failure  to  obtain  satisfactory  results  by  operation 
through  the  canal  is  often  the  result  of  the  extension  of  the 
tympanic  suppuration  to  the  mastoid  interior  by  way  of  the 
antrum,  it  is  with  this  latter  space  that  operative  measures 
for  the  relief  of  the  suppuration  must  be  concerned,  and  in 
considering  the  anatomical  and  surgical  landmarks  inti- 
mately concerned  with  operation  upon  this  region,  one  must 
always  have  in  mind  the  location  of  the  antrum  as  a  basis  for 
safely  removing  the  diseased  tissues  and  as  a  guide  after  it 
has  been  opened  for  the  further  extension  of  the  operative 
field. 

In  relation  to  the  tympanic  cavity,  the  antrum  should  be 
considered  as  an  extension  posteriorly  of  the  epitympanic 
space  or  vault  of  the  tympanum,  and  when  studied  in  this 
aspect,  it  is  as  much  a  part  of  the  tympanic  cavity  as  is  the 
attic  or  any  other  portion,  sharing  in  its  pathological  changes 
and  on  account  of  its  mucous  lining  being  continuous  with 
the  mucoperiosteum  of  the  tympanum,  it  is  in  connection  with 
the  aditus,  an  integral  part  of  the  former  chamber.  As  it  is 
always  that  portion  of  the  temporal  bone  first  involved  in 
the  extension  of  the  suppurative  inflammation  in  its  course 
from  the  tympanum  to  the  mastoid  cells,  it  usually  becomes 
infected  at  a  very  early  period,  and  as  it  is  connected  with 
the  tympanum  proper  in  its  anterior  aspect  by  the  very  small 
aditus,  the  retention  of  purulent  secretion  in  the  mastoid 
cells  is  thus  greatly  enhanced.  The  length  of  the  aditus 
varies  from  3  to  4  millimeters,  and  it  is  placed  directly  oppo- 
site the  opening  of  the  Eustachian  tube  in  the  tympanic  cav- 
ity. The  antrum  in  its  posterior  aspect  is  in  intimate  com- 
munication with  the  pneumatic  cells  of  the  mastoid  process, 
this  relation  being  so  close  that  this  cavity  has  been  com- 
pared to  a  hub  around  which  the  cavities  of  the  temporal 


EXPLANATORY    NOTE    TO    PLATE    XVIII. 


8 


This  plate  shows  a  type  of  a  normal  temporal  bone  with  a  pronounced  convexity 
of  the  mastoid  process. 

i,  Stylo-mastoid  process;  2,  digastric  fossa;  3,  mastoid  process;  4,  supra-meatal 
spine ;  5,  linea  temporalis ;  6,  squamous  plate ;  7,  glenoid  fossa ;  8,  zygomatic  process ; 
9,  osseous  external  auditory  canal. 

184 


PLATE  XVIII 


Anatomical  and  Surgical  Landmarks.          185 

bone  revolve.  Topographically  the  antrum  is  irregular  in 
shape  as  it  passes  backwards  from  the  attic,  and  instead  of 
possessing  the  somewhat  compact  walls  of  the  latter  cavity, 
its  osseous  surroundings  are  more  cellular  in  structure.  In 
relation  to  the  external  semicircular  canal  which  assumes  a 
somewhat  important  position  in  operations  here,  the  antrum 
extends  behind  and  above  it.  The  constant  presence  of  the 
antrum  renders  it  of  the  greatest  importance  in  the  perform- 
ance of  the  various  mastoid  operations,  and  while  other  sur- 
gical landmarks  may  be  absent  or  indistinguishable,  the 
antrum  is  practically  always  present.  A  few  observers  have 
been  unable  to  locate  it  in  a  small  number  of  cases,  but  the 
studies  of  Birmingham  show  that  its  presence  can  be  de- 
pended upon,  as  in  one  hundred  skulls  which  he  studied  in 
this  relation,  the  antrum  was  found  to  be  absent  in  but  one, 
in  which  the  mastoid  was  solid  and  entirely  free  from  pneu- 
matic structure.  Its  size,  while  usually  constant,  yet  varies 
to  some  extent  with  the  nature  of  the  mastoid  structure,  as 
when  the  cellular  system  is  pneumatic  here  the  antrum  is 
large,  while  the  reverse  is  found  the  denser  the  structure  of 
the  former.  From  the  studies  made  by  the  author  quoted, 
the  average  length  of  this  cavity  was  found  to  be  from  12 
to  15  millimeters,  its  width  about  7  and  its  breadth  from 
8  to  10  millimeters,  and  he  also  found  that  the  length  of 
the  tegmen  antri  extended  from  3  to  6  millimeters  above 
the  upper  margin  of  the  external  osseous  canal,  a  point  which 
becomes  of  much  practical  importance  in  its  relation  to  sup- 
purative  changes  in  this  region.  In  relation  to  the  external 
surface  of  the  bone,  its  posterior  aspect  is  placed  nearer  the 
surface  than  is  the  tympanic  cavity,  and  in  those  cases  where 
the  cavity  has  become  enlarged  to  any  degree  from  the  ex- 
tension of  pathological  changes  from  the  tympanum,  and 
especially  when  cholesteatoma  is  present,  this  factor  becomes 
of  great  surgical  importance,  as  in  removing  the  posterior 


1 86  Suppuration  of  the  Middle  Ear. 

and  upper  wall  of  the  external  canal,  the  antrum  being  under 
these  circumstances  so  closely  brought  into  relation  with  the 
canal,  it  is  apt  to  be  opened  at  but  a  slight  depth  from  the 
surface,  while  usually  it  remains  undiscovered  until  the  far 
angle  of  the  postero-superior  portion  of  this  wall  has  been 
reached. 

Above,  the  antrum,  with  the  attic  and  aditus,  is  separated 
from  the  cranal  cavity  only  by  a  thin  bony  roof,  and  opera- 
tive measures  here  must  be  most  carefully  guarded,  both  on 
account  of  the  natural  thinness  of  the  tegmen  and  also  on 
account  of  the  frequency  with  which  dehiscences  are  found ; 
Burkner,  as  quoted  by  Politzer,  having  observed  this  condi- 
tion of  a  defect  in  the  osseous  roof  one  hundred  and  sixty- 
seven  times  in  a  study  of  seven  hundred  and  sixty-five  cases. 
In  relation  to  external  landmarks,  the  antrum  varies  to  some 
extent  as  regards  its  position  during  the  growth  of  the  indi- 
vidual, so  that  the  landmarks  later  to  be  described  alter  their 
position  in  relation  to  the  external  auditory  canal  by  grad- 
ually occupying  a  position  inferior  and  posterior  to  it.  Irre- 
spective of  the  age  of  the  individual,  however,  the  antrum 
remains  inferior  to  the  linea  temporalis,  and  superior  and 
anterior  to  the  squamo-mastoid  suture.  In  the  child  or 
young  adult,  however,  these  landmarks  are  not  always  suffi- 
ciently defined  as  to  be  available  for  operative  purposes,  but 
in  the  adult  it  is  usually  possible  to  clearly  ascertain  their 
presence  and  use  them  as  guides  for  the  opening  of  the 
antrum. 

In  the  vast  majority  of  cases  (see  plate  XVIII),  the 
suprameatal  spine  is  a  constant  landmark,  and  in  the  excep- 
tional cases  in  which  this  is  not  present,  as  pointed  out  by 
Politzer,  the  superior  pole  of  the  ellipse  formed  by  the  ex- 
ternal meatus,  must  be  used  as  a  basis  for  working  down  to 
the  antrum.  Usually  at,  or  somewhat  before,  the  age  of 
puberty,  the  antrum  corresponds  to  a  horizontal  line  drawn 


EXPLANATORY    NOTE    TO    PLATE    XIX. 


5'    3 


A  sagittal  section  of  the  mastoid  process  and  tympanic  cavity  showing  the  rela- 
tions of  its  nerves,  muscles  and  ossicles.  (An  original  drawing  after  Hirschfeld.) 

i,  Stapedius  muscle;  2,  stapes;  3,  membrana  tympani ;  4,  tensor  tympani ;  5, 
facial  nerve ;  6,  large  superficial  petrosal  nerve ;  7,  lesser  superficial  petrosal  nerve ; 
8,  chordi  tympani  nerve;  9,  Gasserian  ganglion;  10,  lenticular  ganglion. 

188 


PLATE  XIX 


Anatomical  and  Surgical  Landmarks.          189 

through  the  spina,  and  instead  of  altering  its  position  in 
relation  to  the  latter,  it  is  quite  fairly  placed  behind  it  at  a 
distance  of  from  5  to  7  millimeters.  As  pointed  out  by  the 
author  last  mentioned,  the  aditus  connecting  the  tympanic 
cavity  with  the  antrum  has  an  average  length  of  from  3  to 
5  millimeters,  it  is  usually  3  millimeters  high  and  from  3 
to  4  millimeters  in  depth,  and  as  it  forms  the  vestibule,  as 
it  were,  of  the  antrum  and  bears  an  important  relation  to 
the  horizontal  portion  of  the  Fallopian  canal  and  horizontal 
semicircular  canal,  it  plays  an  important  role  in  suppurative 
conditions  here.  As  the  attic  or  epitympanic  space  becomes 
a  factor  of  considerable  importance  in  the  surgical  treatment 
of  chronic  suppurative  conditions  of  the  tympanum,  the  most 
important  feature  of  its  anterior  wall  should  be  borne  in 
mind  in  operating  here,  that  is,  the  delicate  lamella  of  bone 
lying  between  the  osseous  walls  of  the  Eustachian  tube  and 
the  internal  carotid  artery,  the  walls  of  the  former  being  con- 
tinuous for  a  short  space  with  the  latter,  and  inasmuch  as 
it  is  generally  essential  in  performing  the  radical  operation 
to  curette  the  tympanic  opening  of  the  tube,  one  should  be 
careful  in  observing  this  close  relationship.  As  usually  con- 
sidered, the  attic  consists  of  that  portion  of  the  tympanic 
cavity  superior  to  a  line  passing  through  the  short  process 
of  the  malleus  and  containing  the  head  and  neck  of  the  mal- 
leus and  the  short  process  and  body  of  the  incus.  The  rela- 
tions of  the  attic  and  its  walls  have  been  already  pointed  out, 
but  it  may  be  mentioned  here  that  its  posterior  wall  is  almost 
entirely  comprised  by  the  aditus,  of  which  the  superior  por- 
tion is,  as  a  rule,  larger  than  the  base,  the  height  of  the 
entrance  from  the  tympanum  being  from  5  to  6  millimeters 
as  an  average.  In  those  cases  where  the  removal  of  the 
carious  and  necrosed  tissue  cannot  be  successfully  performed 
through  the  external  auditory  canal,  the  knowledge  of  the 
relations  between  the  attic,  aditus  and  antrum  is  essential  to 


190  Suppuration  of  the  Middle  Ear. 

successfully  treat  the  morbid  process  by  operative  proced- 
ures, especially  in  those  cases  where  it  is  not  desired  to  reach 
this  region  by  way  of  the  mastoid  route,  but  in  which  Stacke's 
operation  is  more  preferable  by  entering  these  chambers  via 
the  enlarged  external  auditory  canal. 

From  time  to  time  various  evidence  has  been  brought 
forward  in  an  endeavor  to  prove  that  the  nature  of  the  cell 
groupings  in  relation  to  important  structures  can  be  foretold 
by  the  external  appearance  of  the  mastoid  exterior,  or  by  the 
shape  and  configuration  of  the  cranium,  so  that  in  operating 
upon  the  mastoid  region  one  can  avoid  the  lateral  sinus,  etc. 
It  is  very  well  proven,  however,  that  we  can  obtain  little  or  no 
evidence  of  any  practical  value  in  this  way,  except  that  occa- 
sionally some  minor  points  may  be  surmised,  as  for  instance 
in  those  cases  where  the  mastoid  process  is  quite  large  one 
may  as  a  rule  expect  to  find  the  pneumatic  spaces  separated 
by  very  thin  osseous  septa,  with  the  spaces  themselves  larger 
than  normal,  although  this  is  by  no  means  invariably  the 
case.  Okade  has  carefully  studied  this  aspect  of  the  subject, 
and,  as  it  is  of  great  importance  in  relation  to  the  surgery  of 
mastoid  infection  from  chronic  aural  suppuration,  his  results 
are  well  worthy  of  careful  examination.  He  found  that  the 
anthropological  form  of  the  skull  offers  no  trustworthy  evi- 
dence of  the  presence  or  absence  of  the  so-called  dangerous 
temporal  bone,  that  is,  one  characterized  by  a  short  distance 
between  the  transverse  sulcus  and  the  point  of  operation  in 
endeavoring  to  reach  the  antrum.  This  variety  of  temporal 
bone,  however,  is  found  more  frequently  on  the  right  than 
on  the  opposite  side  and  more  often  when  the  mastoid  process 
is  small,  while  most  important  in  this  respect  is  the  forma- 
tion of  the  mastoid,  as  this  dangerous  condition  has  been 
found  to  be  present  in  those  bones  where  the  plane  of  the 
mastoid  forms  an  angle  with  the  axis  of  the  external  audi- 
tory meatus.  In  many  respects  this  bone  resembles  the  mas- 


Anatomical  and  Surgical  Landmarks.          191 

toid  process  of  an  infantile  type,  in  which  there  is  always  a 
close  approximation  of  the  transverse  sulcus  to  the  operative 
field,  and  as  essential  points  in  recognizing  this  condition  as 
far  as  such  is  possible,  one  may  be  led  to  suspect  the  dan- 
gerous proximity  of  the  sinus  when  operating  on  the  right 
side,  if  the  mastoid  process  is  unusually  small,  both  in  its 
external  and  perpendicular  dimensions;  if  an  infantile  type 
of  process  is  present;  if  the  patient  is  below  the  age  of  pu- 
berty ;  if  the  suprameatal  spine  is  markedly  inclined  towards 
the  median  side ;  and  finally,  one  should  expect  this  condition 
more  frequently  in  women  than  in  men. 

Of  some  usefulness  in  selecting  a  site  for  entering  the 
mastoid  process  to  reach  the  antrum  as  the  initial  point,  one 
may  seek  for  the  depression  in  the  bone  immediately  above 
and  behind  the  suprameatal  ridge,  and  when  entering  through 
this  area  the  removal  of  the  bone  in  a  direction  inward,  down- 
ward and  slightly  forward  will  present  an  easy  and  direct 
route  to  the  antrum.  This  space  of  which  further  mention 
will  be  made  in  describing  the  variations  of  the  surgical 
landmarks  in  the  child  may  be  perforated  by  numerous  fora- 
mina containing  vascular  twigs  and  bearing  a  close  relation- 
ship with  the  antral  space,  as  it  very  probably  owes  its  origin 
to  changes  taking  place  in  the  development  of  the  latter. 
The  vascular  zone  varies  to  a  marked  degree  in  different 
individuals,  and  when  not  well  marked  may  be  represented 
by  a  single  sinus-like  depression  with  the  minute  foramina 
perforating  its  base  towards  the  mastoid  interior,  or  it  may 
again  present  itself  as  a  prominent  cup-shaped  cavity  filled 
with  a  varying  number  of  openings  like  a  sieve,  and  of  such 
a  size  that  the  mucosa  of  the  pneumatic  cells  of  the  mastoid 
is  practically  brought  into  direct  communication  with  the 
periosteum  on  the  exterior  of  the  bone.  In  very  young 
children  this  relationship  is  very  close,  the  depression  then 
being  designated  as  the  "spongy  spot,"  and  it  is  in  so  inti- 


192  Suppuration  of  the  Middle  Ear. 

mate  connection  with  the  antrum  that  it  is  separated  from  it 
only  by  a  delicate  layer  of  sieve-like  osseous  tissue,  readily 
broken  down  and  exposing  the  latter  by  but  the  slightest 
force. 

In  selecting  a  point  of  election  for  opening  the  antrum, 
Macewen's  triangle  will  usually  form  a  most  reliable  guide, 
as  this  operator  found  in  four  hundred  and  fifty  temporal 
bones  that  his  triangle  was  well  defined  in  four  hundred  and 
twenty-six,  while  it  was  recognizable  in  twenty-two,  making 
it  for  practical  purposes  an  almost  constant  guide  in  such 
operative  procedures.  This  area  is  located  by  its  relations 
to  the  posterior  and  superior  walls  of  the  external  auditory 
canal,  and  its  position  has  been  described  by  Bench  as  being 
formed  by  a  horizontal  line  drawn  tangent  to  the  superior 
wall  of  the  external  auditory  canal,  while  a  second  line  is 
drawn  vertical  and  tangent  to  the  posterior  wall,  so  that  the 
point  of  intersection  of  the  two  lines  will  form  the  apex  of 
the  triangle,  its  base  will  be  defined  by  the  curved  border  of 
the  meatus  lying  between  the  points  of  tangency  of  these 
two  lines,  and  beneath  the  triangle  thus  outlined  will  be  found 
the  antrum.  The  extent  of  the  operative  triangle  as  regards 
safety  may  often  be  influenced  by  the  size  of  the  mastoid 
process,  as  it  will  usually  be  found  to  be  the  case  that  when 
the  mastoid  is  small,  pointed  and  narrow,  the  groove  for  the 
lateral  sinus  will  be  deeply  placed,  while  the  operative  limits 
of  this  triangle  will  be  contracted.  While,  when  the  reverse 
of  this  condition  is  found,  that  is,  when  the  bone  is  blunt, 
rounded  and  broad  in  area,  the  triangle  of  election  becomes 
correspondingly  increased  in  its  diameters,  and  the  sinus, 
being  placed  further  away  from  the  posterior  canal  wall, 
allows  a  larger  area  for  safely  opening  the  antrum. 

The  suprameatal  spine  or  spine  of  Henle  offers  a  most 
reliable  guide  and  is  one  of  the  best  landmarks  in  opening 
the  mastoid  process  in  order  to  accurately  and  safely  enter 


EXPLANATORY    NOTE    TO    PLATE    XX. 


A  sagittal  section  of  the  mastoid  process  on  a  plane  with  the  facial  nerve.  The 
course  of  the  carotid  artery  through  the  petrous  portion  of  the  temporal  bone  is  shown. 
(An  original  drawing  after  Hirschfeld.) 

i,  Opened  aquseductus  Fallopii ;  2,  fenestra  ovalis ;  3,  hiatus  Fallopii;  4,  point  of 
emergence  of  the  superficial  petrosal  nerve ;  5,  cerebral  surface  of  the  petrous  portion 
of  the  temporal  bone ;  6,  osseous  opening  of  the  Eustachian  tube ;  7,  promontory ;  8, 
fenestra  rotunda;  9,  mastoid  cells;  10,  internal  carotid  artery. 

194 


PLATE  XX 


Anatomical  and  Surgical  Landmarks.          195 

the  antrum.  It  is  situated  as  a  more  or  less  prominent 
osseous  plate  or  projecting  surface,  superior  and  posterior 
to  the  upper  and  back  wall  of  the  external  canal,  imme- 
diately below  the  supramastoid  ridge,  and  as  a  rule,  it  is 
curved  in  nearly  a  concentric  position  in  relation  to  the  cir- 
cumference of  the  aural  opening,  with  its  upper  portion  being 
slightly  placed  more  anteriorly  than  its  lower.  In  some 
cases  it  projects  but  very  slightly  above  the  osseous  level, 
and  is  thus  rendered  somewhat  difficult  of  localization  until 
the  soft  tissues  have  been  pushed  well  back  over  this  area 
and  by  drawing  the  handle  of  the  scalpel  over  the  exposed 
bone,  the  elevation  of  the  spina  can  usually  be  located  in 
practically  all  cases.  While  in  connection  with  the  depression 
of  the  bone  immediately  above  it,  the  spina  is  probably  our 
best  guide,  yet  some  differences  of  opinion  exist  as  to  its 
constant  presence.  Kiesselbach  in  one  hundred  temporal 
bones  examined  found  it  eighty-two  times;  Schultze  one 
hundred  and  nine  times  in  one  hundred  and  twenty  tem- 
poral bones;  while  Lemoir  in  two  hundred  adult  skulls 
which  he  examined  for  this  purpose,  found  it  was  absent 
in  but  one,  although  in  twenty  instances  it  was  not  well 
marked  and  required  some  care  to  ascertain  its  presence.  As 
has  been  stated  elsewhere,  "the  spine  of  Henle  will  seldom 
fail  and  will  never  mislead,"  and  if  in  looking  for  it  after 
the  primary  incision  has  been  made  by  carefully  going  over 
the  mastoid  surface  in  this  particular  location,  one  will  be 
able  by  making  the  opening  in  the  bone  on  a  horizontal  line 
from  4  to  8  millimeters  posterior  to  it,  to  obtain  a  route 
parallel  to  the  external  canal  and  slightly  inclined  upward, 
that  will  reach  the  antrum  at  a  depth  of  from  10  to  15  milli- 
meters in  the  vast  majority  of  cases  operated  upon.  While 
the  location  of  this  landmark  practically  never  varies  in  the 
adult  temporal  bone,  as  regards  its  value  as  a  surgical  guide, 
its  size  and  appearance  does  vary,  however,  in  many  in- 


196  Suppuration  of  the  Middle  Ear. 

stances,  as  in  addition  to  its  physical  characteristics  already 
mentioned,  it  may  be  represented  by  a  flattened  projection 
of  bone  separated  from  the  supramastoid  ridge  by  an  aver- 
age distance  of  6  millimeters.  Or  again,  it  may  project  as 
a  sharp-pointed  spine  springing  backwards  and  upwards 
from  the  auditory  canal,  and  thus  marking  the  posterior 
margin  of  the  meatus,  so  that  in  these  cases  its  detection 
presents  no  difficulties  at  all,  and  the  point  of  election  for 
opening  the  bone  just  posterior  to  it  can  be  ascertained  at 
a  glance.  As  pointed  out  by  Kiesselbach,  this  osseous  spine 
at  the  lower  margin  of  the  perpendicular  part  of  the  squama 
is  only  found  on  adult  temporal  bones.  Just  behind  the  su- 
prameatal  spine,  and  therefore  in  close  relation  to  the  posi- 
tion where  the  planum  mastoideum  passes  into  the  posterior 
wall  of  the  external  canal  is  the  fossa  which  Yearsley  believes 
to  be  always  present,  although  it  may  be  a  mere  dimple 
on  the  surface,  and  which  he  considers  as  a  more  accurate 
guide  than  the  former.  In  relation  to  the  floor  of  the  middle 
cerebral  fossa,  the  spine  of  Henle  is  at  the  nearest  point 
about  6  millimeters  below  it,  and  one  can  be  fairly  certain 
in  operating  here  that  the  cranial  cavity  is  never  lower  than 
the  spina,  as  in  one  thousand  skulls  examined  in  reference 
to  this  point,  Randall  found  it  as  low  as  the  spine  in  but  five. 
The  length  of  the  postero-superior  canal  wall  should  also 
be  considered  in  estimating  the  probable  depth  of  the  Fallo- 
pian and  horizontal  semicircular  canals.  The  length  of  the 
canal  varies  to  a  considerable  extent  in  different  individuals, 
its  average  length,  measured  from  the  spine  of  Henle,  being 
from  12  to  17  millimeters.  For  practical  purposes,  the  depth 
of  the  overlying  soft  tissue  must  also  be  taken  into  account, 
as  they  usually  double  this  distance.  For  this  reason,  there- 
fore, one  is  very  apt  to  go  astray  when  the  soft  parts  are  in 
situ,  and  in  all  cases  where  it  is  desired  to  open  the  antrum 
the  measurements  as  to  the  depth  to  which  one  can  safely 


EXPLANATORY    NOTE    TO    PLATE    XXI. 


An  anatomical  plate  showing  the  inner  surface  of  the  temporal  bone  and  exposing 
the  internal  ear.  (An  original  drawing  after  Hirschfeld.) 

i,  External  auditory  canal ;  2,  ossicles ;  3,  vestibular  cavity ;  4,  stapes ;  5,  superior 
semicircular  canal ;  6,  posterior  semicircular  canal ;  7,  horizontal  semicircular  canal ; 
8,  cochlea ;  9,  internal  auditory  canal. 

198 


PLATE  XXI 


Anatomical  and  Surgical  Landmarks.          199 

penetrate  into  the  mastoid  interior  in  order  to  reach  the 
antrum  should  be  made  from  the  suprameatal  spine  or  the 
opening  in  the  bone  at  this  point.  Broca  states  that  the 
depth  of  the  antrum  depends  on  the  age  of  the  subject  and 
also  varies  at  an  equal  age  in  different  individuals.  In  in- 
fants it  is  but  2  to  4  millimeters  from  the  mastoid  cortex, 
and  is  readily  penetrated  by  slight  pressure  with  a  curette 
over  the  spongy  spot.  As  a  result  of  this  variation  in 
depth,  he  states  that  if  the  rule  is  laid  down  to  cease  oper- 
ating if  the  antrum  is  not  found  at  5  or  6  millimeters  (Polit- 
zer),  at  20  millimeters  (Noltenius),  or  at  25  millimeters 
(Schwartze),  one  risks  missing  an  antrum  which  possibly 
is  present.  Holmes,  in  measurements  made  to  determine 
these  points,  the  spine  being  used  to  determine  the  fixed 
point  from  which  the  measurements  were  made,  found  the 
distance  from  the  suprameatal  spine  to  the  facial  nerve 
to  be  15  millimeters;  to  the  horizontal  semicircular  canal 
16;  to  the  posterior  semicircular  canal  18;  to  the  foot 
plate  of  the  stapes  22;  and  to  the  end  of  the  short  process 
of  the  incus  16  millimeters,  and  based  upon  these  studies 
he  further  states  that  the  only  safe  guide  as  to  the  extreme 
distance  that  we  may  penetrate,  is  the  distance  from  the 
spine  to  the  postero-superior  margin  of  the  drum  membrane, 
which  varies  but  little  from  15  millimeters.  In  a  recent 
study  of  thirty  temporal  bones  in  reference  to  the  antrum, 
Kerrison  measured  the  thickness  of  the  osseous  tissue  sepa- 
rating the  antrum  from  the  cortex,  and  was  able  to  demon- 
strate three  facts.  He  found  that  in  different  specimens 
much  greater  variations  existed  as  to  the  length  of  the  bony 
meatus  than  are  usually  considered  in  most  text  books.  The 
depth  of  the  antrum  was  always  less  by  actual  measurements 
than  the  postero-superior  canal  wall  and  that  the  depth  of 
the  antrum  rarely,  if  ever,  exceeds  15  millimeters.  In  these 
bones,  the  length  of  the  posterior  canal  wall  varied  from 


200  Suppuration  of  the  Middle  Ear. 

12  to  1 8  millimeters,  and  the  depth  of  the  antrum  from  6 
to  15  millimeters,  and  as  a  result  of  these  figures,  he  suggests 
that  in  operations  on  the  mastoid,  the  antrum  should  always 
be  approached  from  the  nearest  point  upon  the  cortex,  which 
in  the  great  majority  of  temporal  bones  is  the  small  triangu- 
lar space  just  behind  the  spine  of  Henle.  This  point  not 
only  furnishes  a  guide  to  the  site  of  the  antrum,  but  gives 
fairly  accurate  data  as  to  the  depth  beyond  which  it  is  not 
safe  to  proceed.  The  depth  of  the  antrum  is  always  less 
than  the  length  of  the  postero-superior  wall  of  the  meatus, 
and  finally  in  attempting  to  expose  the  antrum,  the  depth  of 
15  millimeters  should  be  the  extreme  limit  of  safety. 

Two  important  structures  by  their  location  must  always 
enter  into  the  most  serious  consideration  in  the  performance 
of  a  mastoid  operation,  namely,  the  facial  nerve  and  the  lat- 
eral sinus,  the  position  of  which  influence  to  some  extent  the 
methods  employed  in  entering  the  antrum.  Inasmuch  as  the 
relations  of  the  external  semicircular  canal  are,  as  regards 
the  treatment  of  chronic  aural  suppuration,  in  intimate  con- 
nection with  the  Fallopian  canal,  these  two  structures  may  be 
here  considered  together.  After  the  prominent  facial  canal 
has  formed  the  upper  border  of  the  oval  window,  it  can  be 
recognized  as  it  passes  a  few  millimeters  anteriorly  to  become 
blended  with  the  geniculate  ganglion,  where  it  no  longer  pos- 
esses  surgical  interest  in  this  connection,  as  it  becomes  pro- 
tected from  surgical  traumatism  by  its  deeper  penetration  into 
the  petrous  portion  of  the  temporal  bone.  At  this  point  the 
nerve  is  brought  into  relation  with  the  tensor  tympani  muscle, 
the  former  lying  to  the  inner  side  of  the  muscle  and  its  par- 
tially formed  osseous  canal.  Posteriorly  to  the  oval  window, 
the  nerve  assumes  great  importance  on  account  of  the  danger 
of  wounding  it  here  during  the  various  procedures  of  the 
post-auricular  operation.  With  a  well-marked  curve  from 
this  point,  the  nerve  then  descends  so  that  it  passes  but  a 


Anatomical  and  Surgical  Landmarks.          201 

millimeter  or  so  from  the  posterior  edge  of  the  tympanic 
annulus,  and  then  again  loses  its  importance  as  a  surgical 
landmark  as  it  passes  in  a  vertical  direction  to  its  exit  from 
the  bone,  through  the  stylo-mastoid  foramen.  Both  the  facial 
and  semicircular  canals,  by  their  projection,  narrow  the 
aditus  at  the  point  where  the  horizontal  portion  of  the  nerve 
passes  directly  in  relation  with  the  tympanic  entrance  of  the 
aditus,  immediately  preceding  its  bend  as  it  passes  down- 
wards. As  the  position  assumed  by  the  nerve  posterior  to 
the  margin  of  the  tympanic  ring  becomes  vertical,  the  nerve 
enters  the  anterior  limits  of  the  mastoid  process,  where,  as 
it  descends  downwards,  it  passes  somewhat  outwards  and 
backwards,  so  that  it  is  in  intimate  relation  with  the  posterior 
wall  of  the  external  canal  at  the  junction  of  the  middle  and 
lower  third.  As  the  facial  nerve  in  this  portion  of  its  course 
passes  through  dense,  compact  osseous  tissue,  inasmuch  as 
this  part  of  the  temporal  bone  forms  here  the  lower  portion 
of  the  posterior  wall  of  the  tympanum  and  the  lower  and 
posterior  walls  of  the  external  canal,  the  so-called  facial  spur 
is  found  at  this  point  and  in  doing  the  radical  operation  it 
acts  as  a  danger  mark,  as  it  must  be  avoided  in  order  to  pre- 
vent injury  to  the  nerve.  The  bony  canal  at  this  point  is 
exceedingly  dense  in  the  normal  state  and  is  deeply  situated, 
unlike  the  elbow  of  the  horizontal  portion  of  the  nerve  which 
is  often  very  thin  and  sometimes  deficient,  so  that  if  care 
be  used  by  protecting  it,  one  can  usually  avoid  wounding  the 
nerve  in  this  situation,  if  this  area  be  not  trespassed  upon. 
As  a  valuable  indication  in  avoiding  the  nerve  here,  is  the 
appearance  of  a  line  of  dense  bone  in  the  operative  field, 
and  when  such  tissue  is  encountered  at  any  position  in  the 
course  of  the  facial  nerve,  one  should  be  very  careful  in  the 
employment  of  the  chisel  or  sharp  spoon.  This  is  especially 
so  in  removing  the  wall  of  the  aditus  and  in  performing  this 
part  of  the  operation,  it  is  always  wisest  to  use  the  chisel  at 


202  Suppuration  of  the  Middle  Ear. 

such  a  height  that  the  elbow  of  the  canal  containing  the  nerve 
will  not  be  damaged,  this  usually  being  accomplished,  if  the 
excavation  of  the  mastoid  inward  is  not  allowed  to  pass 
below  the  level  of  the  suprameatal  fossa  or  the  spine  of 
Henle,  so  that  the  nerve  will  then  not  be  subjected  to  trau- 
matism,  although  in  some  cases  where  the  osseous  destruc- 
tion is  extensive  this  is  not  always  possible.  Randall  states 
that  the  facial  canal  is  never  less  than  16  millimeters  from  a 
point  5  millimeters  behind  the  spina  and  its  anatomical  guide 
is  the  polished  boss  or  bony  prominence  on  the  inner  wall 
of  the  antrum  which  marks  the  protuberance  of  the  hori- 
zontal semicircular  canal  and  the  downward  curving  con- 
vexity of  the  facial  canal,  and  from  this  point  its  descent 
is  exactly  vertical.  He  further  states  that  the  method  of 
operation  should  be  such  that  it  furnishes  a  perfect  guard 
to  the  facial  nerve,  and  if  possible,  this  should  be  obtained 
by  the  natural  structures,  rather  than  by  any  instrument 
which  may  perpetrate  the  injury  which  it  is  devised  to  pre- 
vent. If  the  operation  is  done  from  a  point  near  the  an- 
nulus,  it  is  feasible  to  open  the  aditus  from  the  canal  with 
great  security  to  the  nerve,  as  the  margin  of  the  Rivinian 
segment  remains  between  it  and  the  chisel  as  a  bridge  against 
which  we  can  safely  chisel  until  it  is  too  delicate  to  afford 
further  protection,  when  it  is  easily  broken  away  by  outward 
traction  with  the  spoon,  so  that  the  opening  into  the  antrum 
and  attic  needs  but  such  additional  enlargement  as  the  con- 
dition of  the  carious  process  demands.  When  the  mastoid 
and  tympanic  cavity  are  to  be  eviscerated,  he  finds  it  more 
convenient  to  open  the  mastoid  first  and  to  remove  the  pos- 
terior wall  of  the  meatus  between  the  canal  and  mastoid 
cavities,  antrum  and  attic,  by  rongeur  or  chisel,  working 
from  without  inwards,  the  same  bony  margin  being  pre- 
served as  a  guard  until  the  last  steps  of  the  procedure,  will 
bridge  the  gap  directly  over  the  nerve.  Leading  apparently 


EXPLANATORY    NOTE    TO    PLATE    XXII. 


1 


This  plate  shows  the  external  surface  of  the  temporal  bone  of  the  new-born 
infant.  Observe  the  flat  character  of  the  bone  due  to  the  absence  of  the  angle  between 
the  annulus  tympanicus  and  the  squamous  portion.  Also  the  absence  of  the  mastoid 
process  and  the  relative  disproportion  between  the  size  of  the  drum  membrane  and 
the  bone  itself. 

i,  Squamous  plate;  2,  zygomatic  process;  3,  glenoid  fossa;  4,  handle  of  the 
malleus ;  5,  membrana  tympani ;  6,  annulus  tympanicus. 

204 


PLATE  XXII 


Anatomical  and  Surgical  Landmarks.          205 

outward  from  this,  the  ridge  constituted  by  the  anterior 
wall  of  the  mastoid  can  be  cut  down  as  far  as  the  middle  of 
the  annulus  and  thence  outward  in  a  steep  slope  which  can 
approximate  the  vertical  course  of  the  descending  part  of 
the  facial  nerve.  The  descending  portion  of  the  nerve, 
which  is  therefore  the  most  important  part  from  the  surgical 
standpoint,  is  almost  universally  perpendicular  and  occupies 
an  almost  constant  relation  to  the  inner  end  of  the  auditory 
canal,  and  as  shown  by  Randall  in  a  series  of  one  hundred 
skulls,  practically  no  variations  in  its  course  were  found. 

Jones,  in  studying  the  anatomical  relations  of  the  facial 
nerve  in  relation  to  the  mastoid  operation,  states  that  if  we 
bear  in  mind  the  constant  relation  of  the  nerve  to  the  tym- 
panic ring,  we  shall  not  be  led  to  think  in  bones  in  which 
the  tympanic  ring  and  mastoid  process  are  more  or  less 
rudimentary,  that  the  facial  canal  is  further  in  than  it 
really  is,  independently  of  measurements  from  the  surface. 
As  Stiles  has  shown,  the  nerve  in  young  children  is  ex- 
posed to  danger  at  its  exit  from  the  stylo-mastoid  foramen, 
even  from  the  knife  used  in  incising  the  soft  parts.  In 
adults  the  angle  of  inclination  of  the  facial  canal,  the  point 
at  which  it  intersects  the  plane  of  the  tympanic  ring  and  the 
relation  of  its  lower  part  to  the  highest  point  in  the  curved 
floor  of  the  external  meatus,  enables  one  to  tell  how  much 
of  the  osseous  wall  can  be  safely  removed  in  the  Stacke- 
Schwartze  operation.  As  the  outward  and  backward  incli- 
nation of  the  facial  canal  brings  it  into  relation  in  its  lower 
half  with  the  petrous  or  deeper  mastoid  cells,  a  knowledge 
of  the  relation  of  the  nerve  posterior  to  the  highest  point 
of  the  meatal  floor  is  of  value  when  a  sinus  has  formed  be- 
tween the  meatus  and  mastoid  cells.  While  the  proximity 
of  the  nerve  to  the  inner  part  of  the  tympanic  ring  and  the 
floor  of  the  iter  exposes  it  to  danger  during  the  introduction 
of  Stacke's  protector,  either  by  its  point  entering  the  sinus 


206  Suppuration  of  the  Middle  Ear. 

tympani  instead  of  the  iter,  or  by  backward  pressure  on  the 
floor  and  inner  wall  of  the  iter.  Broca,  in  some  recent 
studies,  states  that  the  horizontal  part  of  the  facial  canal, 
with  its  elbow,  that  passes  under  the  threshold  of  the  aditus 
is  protected  only  by  a  lamella  of  bone  that  is  sometimes  ex- 
tremely thin.  If  in  a  child  we  seek  the  antrum,  which  is 
high,  the  opening  is  absolutely  without  danger  to  the  facial 
nerve,  and  if  when  the  antrum  is  exposed  we  demolish  the 
outer  wall  of  the  aditus,  the  nerve  is  secure  from  risk,  pro- 
vided that  in  making  the  inferior  cut  with  the  chisel,  we 
incline  the  instrument  a  little  upwards.  In  the  adult  antrum, 
however,  behind  the  meatus  the  inferior  extremity  is  there 
separated  by  the  elbow  of  the  facial.  On  an  average  Nol- 
tenius  found  the  distance  separating  the  spina  and  the  facial 
canal  to  be  13  millimeters  in  depth.  The  safest  average  to 
take,  however,  is  10  millimeters,  while  the  best  precaution  is 
not  to  make  the  opening  too  low  in  the  bone,  but  as  soon  as 
the  aditus  comes  into  view  one  is  master  of  the  situation,  as 
the  location  of  the  facial  nerve  is  then  known.  To  deter- 
mine these  relations  of  the  facial  nerve,  Joyce  measured 
thirty  bones  so  as  to  find  the  exact  distance  from  the  surface 
to  the  nerve  in  the  location  usually  selected  for  the  mastoid 
operation,  and  each  bone  was  drilled  vertically  from  the  sur- 
face to  the  aqueductus  Fallopii  in  three  places,  first,  at  a 
point  immediately  behind  the  center  of  the  external  audi- 
tory meatus;  secondly,  at  a  point  immediately  behind  the 
upper  border  of  the  same;  and  thirdly,  at  a  point  above  the 
center  of  the  meatus.  From  the  first  point  the  average  dis- 
tance to  the  nerve  was  16.75  millimeters;  from  the  second 
18.5  millimeters,  with  a  minimum  of  14.75,  while  from  the 
last  named  position,  the  distance  was  19.4  millimeters,  with 
a  minimum  of  16.25.  As  a  result  of  these  investigations  he 
concludes  that  the  facial  canal  lies  altogether  in  front  of  the 
mastoid,  and  that  a  drill  sent  straight  in  from  any  point  on 


Anatomical  and  Surgical  Landmarks.          207 

the  surface  of  the  latter  cannot  injure  the  nerve.  As  meas- 
ured from  the  second  position,  the  facial  nerve  is  in  43.3  per 
cent,  of  cases  more  superficial  than  the  external  semicircular 
canal,  while  in  the  same  percentage  of  cases  this  was  re- 
versed, and  in  13.4  per  cent,  both  were  the  same  distance 
from  the  surface.  Thus  the  external  semicircular  canal 
cannot  be  taken  as  a  guide  to  the  depth  of  the  facial  canal. 
He  also  finds  that  the  average  distance  of  the  facial  nerve 
from  the  second  point  is  slightly  less  than  that  of  the  external 
semicircular  canal,  and  in  removing  the  outer  wall  of  the 
attic,  this  canal  is  in  91  per  cent,  nearer  the  third  point  than 
the  facial;  however,  as  it  is  1.5  millimeters  higher  than  the 
facial  nerve,  it  is  almost  out  of  danger,  besides  it  has  a 
thicker  covering  of  compact  bone  here  in  the  attic  than  has 
the  nerve. 

In  addition  to  the  points  already  mentioned  as  regards 
the  horizontal  semicircular  canal,  its  position  immediately 
back  of  the  inner  wall  of  the  aditus  and  above  the  aqueductus 
Fallopii  renders  it  fairly  well  protected  from  operative  trau- 
matism,  although  it  may  sometimes  be  damaged  if  the  mas- 
toid  opening  is  continued  beyond  the  level  of  the  internal  wall 
of  the  tympanum,  but  this  should  never  happen  in  careful 
hands,  and  if  a  protector  be  placed  here,  it  is  practically  im- 
possible to  do  the  canal  any  harm.  Even  if  one  should  not 
be  accurately  satisfied  as  to  its  location  in  any  particular 
case,  it  is  fairly  well  protected  and  offers  considerable  resist- 
ance to  instrumentation  by  the  thick  and  firm  osseous  tissue 
which  surrounds  it. 

The  structure  of  the  mastoid  of  necessity  in  this  connec- 
tion assumes  considerable  importance  in  relation  to  oper- 
ations upon  this  portion  of  the  temporal  bone,  and  as  a 
rule  one  may  classify  the  processes  under  the  three  well- 
known  divisions:  the  pneumatic  (see  plate  XXIV),  in  which 
large  cell  spaces  occupy  the  bulk  of  the  mastoid  and  to 


208  Suppuration  of  the  Middle  Ear. 

a  greater  or  lesser  extent  communicate  with  one  another 
and  with  the  antrum;  the  diploic  type  (see  plate  XXV), 
in  which  the  cells  are  very  small  and  somewhat  indepen- 
dent of  each  other;  and  the  sclerotic  variety,  in  which  the 
bone  is  hard,  compact  and  practically  devoid  of  a  cellular 
structure.  In  the  oft-repeated  and  valuable  studies  of 
Zuckerkandl,  in  regard  to  this  point,  36  per  cent,  of  the 
temporal  bones  examined  belonged  to  the  first  type,  20  per 
cent,  to  the  second,  and  in  42  per  cent,  both  of  these  types 
were  present  in  varying  degree.  A  thorough  knowledge  of 
the  distribution  and  major  variations  of  the  mastoid  cells  is 
as  essential  to  the  proper  appreciation  of  the  pathology  and 
surgery  of  chronic  suppurative  otitis  as  is  a  knowledge  of 
the  antrum  or  any  other  portion  of  the  temporal  bone,  and 
it  is  only  by  a  thorough  understanding  of  their  relationship 
and  their  extensive  distribution  that  one  can  successfully 
remove  the  diseased  tissue  with  any  degree  of  safety  in  the 
larger  number  of  cases  of  chronic  tympanic  suppuration  in 
which  operative  measures  are  indicated.  Before  entering 
the  inner  structure  of  the  mastoid  process,  one  usually  finds 
the  cortex  varying  greatly  in  thickness,  depending  upon  the 
age  of  the  patient  within  somewhat  indefinite  limits,  and  also 
upon  the  nature  and  duration  of  the  pathological  changes 
present  in  the  individual  case.  During  early  childhood  it  is 
usually  very  thin  and  may  readily  be  penetrated  with  but 
little  force,  while  in  the  adult  it  may  vary  in  thickness  from 
2  to  5  millimeters  or  even  more,  especially  in  those  cases 
where  the  inflammatory  process  has  occasioned  a  great  in- 
crease in  the  thickness  and  density  of  this  tissue.  The  pneu- 
matic type  of  process  varies  greatly  in  the  arrangement  and 
extent  of  its  cellular  development,  although  in  all  temporal 
bones,  irrespective  of  the  size  or  number  of  the  cells,  it  has 
been  very  clearly  demonstrated  that  the  mastoid  cells  are  but 
annexes  of  the  antrum.  In  some  instances  the  cells  are  large 


EXPLANATORY    NOTE    TO    PLATE    XXIII. 


This  plate  shows  the  internal  surface  of  the  temporal  bone  of  the  new-born 
infant.  Observe  the  rudimentary  state  of  the  mastoid  process. 

i,  Inner  view  of  squamous  plate ;  2,  rudimentary  mastoid  process ;  3,  incus ;  4, 
malleus ;  5,  membrana  tympani ;  6,  annulus  tympanicus. 


210 


PLATE  XXIII 


Anatomical  and  Surgical  Landmarks.         211 

in  number,  irregular  in  shape,  and  to  a  great  extent  extend 
in  various  directions,  while  in  other  specimens,  the  mastoid 
process  may  be  entirely  or  in  great  part  composed  of  but 
one  or  two  enormous  cell  dilatations,  with  or  without  smaller 
scattered  cells  in  immediate  relation  to  them.  In  cases  of 
the  former  class  the  mastoid  cortex  is  apt  to  be  quite  thin, 
while  in  the  latter,  it  is  even  more  so,  and  the  large  size  of 
the  cell  or  cells  may  cause  it  to  have  a  much  more  convex 
surface  than  is  usually  observed.  Especially  may  this  be  the 
case  on  the  internal  surface  of  the  apex  of  the  process. 
While  the  pneumatic  cells  may  be  very  large,  as  just  de- 
scribed, they  do  not  necessarily  communicate  with  each  other 
or  with  the  antrum  by  proportionally  large  openings,  as  it 
is  often  common  to  find  in  such  cases  that  the  communicating 
spaces  are  quite  small.  Where  the  larger  spaces  are  numer- 
ous, they  may  extend  from  the  antrum  as  far  as  the  occipital 
bone  posteriorly  and  embracing  in  great  part  the  sinus  and 
inferiorly  they  may  reach  well  to  the  cortex  of  the  apex, 
while  above  and  in  front,  the  cells  may  to  a  considerable 
extent  surround  the  auditory  canal  and  even  extend  well  up 
to  the  temporal  ridge.  As  to  the  extent  to  which  the  patho- 
logical process  may  be  influenced  by  the  cell  development, 
the  carious  process  may  involve  their  walls,  when  numerous, 
as  far  inwards  as  the  apex  of  the  petrous  portion  of  the  tem- 
poral bone,  and  they  may  even  surround  the  labyrinth,  be 
in  relation  to  the  bulb  of  the  jugular  vein  and  part  of  the 
carotid  canal.  Broca  classifies  these  cells  into  various 
groups,  and  says  that  only  the  true  mastoid  cells  are  situated 
below  a  horizontal  line  passing  near  the  junction  of  the  upper 
third  with  the  lower  two-thirds  of  the  meatus. 

The  squamous  cells  are  in  that  part  of  the  squamous 
bone  which  contributes  to  the  formation  of  the  posterior  wall 
of  the  external  meatus,  while  some  of  them  form  in  contact 
with  the  meatus,  the  group  of  cells  bordering  it.  These  are 


212  Suppuration  of  the  Middle  Ear. 

sometimes  prolonged  above  and  even  in  front  into  the  root 
of  the  zygoma  and  above  the  temporo-maxillary  articulation. 
The  petrous  cells  occupy  the  base  of  the  process  above  a 
horizontal  line  passing  through  the  junction  of  the  upper 
third  and  lower  two-thirds  of  the  meatus;  in  front  they  are 
limited  by  the  arched  premastoid  -lamina,  and  behind  they 
extend  towards  the  lateral  sinus,  in  front  of  which  they  may 
extend  almost  to  the  occipital  bone.  In  some  cases  the  an- 
trum  may  be  hidden  by  a  convex  septum,  and  if  the  cell 
which  is  bounded  behind  by  this  septum  is  very  large,  one 
may  think  that  the  antrum  has  been  opened,  but  search  in 
the  superior  angle  of  this  false  antrum  with  the  probe  fails 
to  find  the  narrow  opening  of  the  aditus,  and  by  excavating 
below  and  under  this  lamella,  the  antrum  is  reached  at  the 
level  of  the  spine  of  Henle.  While  the  diploic  type  of  mas- 
toid  usually  contains  a  few  fair-sized  pneumatic  cells,  yet  its 
structure  in  great  part  is  composed  of  numerous  very  small 
cells  and  presents  the  typical  histological  structure  of  diploic 
tissue.  The  third  type,  in  which  sclerotic  tissue  predominates, 
is  usually  associated  in  part  with  diploic  tissue,  and  it  seems 
highly  probable  that  this  variety  of  mastoid  is  responsible 
for  its  dense,  ivory-like  structure  in  many  cases  by  gradual 
pathological  changes,  the  entire  mastoid  process  in  such  in- 
stances being  smaller  in  size  than  the  pneumatic  type.  In 
addition  to  these  another  type  has  been  described  in  which 
the  lower  part  is  diploic  and  the  upper  pneumatic,  or  the 
posterior  and  lower  part  may  be  diploic,  while  the  superior 
portion  possesses  a  pneumatic  structure.  In  exceptional 
cases  aberrant  cells  may  be  present  in  the  mastoid  process, 
and  from  their  unusual  location  they  are  apt  to  be  over- 
looked, or  remain  entirely  undiscovered,  and  if  the  seat  of 
infection  may  seriously  compromise  the  entire  result  of  the 
operation.  This  condition  is  quite  unusual,  however,  but  is 
well  shown  in  a  case  reported  by  Moure  and  LaFarella,  in 


EXPLANATORY    NOTE    TO    PLATE    XXIV. 


An  original  anatomical  section  through  the  temporal  bone.  The  pneumatic  type 
of  mastoid  cells  are  shown. 

i,  Large  tip  cell ;  2,  pneumatic  variety  of  cell ;  3,  facial  canal ;  4,  inner  surface  of 
tympanum ;  5,  aditus  ad  antrum ;  6,  mastoid  antrum. 

214 


PLATE  XXIV 


k  Anatomical  and  Surgical  Landmarks.          215 

which  the  mastoid  process  was  cleaned  out  and  all  diseased 
tissue  was  removed  down  to  the  healthy  bone  and  prompt 
healing  took  place.  One  month  later,  however,  symptoms 
of  meningitis  developed,  the  patient  died  and  autopsy  showed 
that  the  cause  of  the  trouble  was  an  aberrant  pneumatic  cell 
filled  with  pus  in  the  posterior  part  of  the  mastoid,  above  a 
plane  passing  through  the  upper  border  of  the  external 
meatus  and  one  centimeter  behind  a  line  passing  through  the 
tip  of  the  mastoid.  This  cell  was  completely  separated  from 
the  operation  cavity  by  a  wall  of  healthy  bone  0.5  centimeter 
in  thickness  and  limited  internally  by  the  lateral  sinus,  while 
the  entire  operated  area  was  found  to  be  perfectly  healthy. 

The  squamo-mastoid  suture  forms  a  landmark  of  not  in- 
considerable importance,  as  it  forms  one  side  of  the  triangle 
previously  described  in  connection  with  the  linea  temporalis, 
and  the  external  auditory  canal,  and  while  it  is  of  necessity 
always  present,  it  is  frequently  inconspicuous  and  not  avail- 
able as  a  surgical  landmark.  When  it  can  not  be  recog- 
nized by  the  finger,  however,  its  location  may  sometimes  be 
ascertained  during  the  stripping  of  the  periosteum  from  the 
bone  by  the  furrow  adhering  very  closely  to  this  point  and 
either  a  delicate  white  line  left  will  enable  one  to  recognize 
it,  or  it  may  be  found  by  the  shreds  of  periosteum  which  can- 
not be  removed  from  this  point.  In  the  mastoid  interior 
traces  of  the  suture  may  also  occasionally  be  found  as  a  more 
or  less  well-defined  osseous  wall  beneath  the  location  of  the 
furrow  on  the  cortex  and  not  infrequently  limiting  to  some 
extent  a  single  large  cell  or  a  group  of  smaller  pneumatic 
spaces. 

The  linea  temporalis  is  a  most  important  and  usually  con- 
spicuous landmark  and  one  of  the  external  anatomical  points 
already  described,  that  indicates  a  safe  passage  to  the  antrum 
and  the  avoidance  of  the  lateral  sinus.  Of  the  three  promi- 
nent landmarks  in  this  region,  that  is,  the  temporal  ridge, 


216  Suppuration  of  the  Middle  Ear. 

the  spine  of  Henle  and  the  squamo-mastoid  suture,  the 
first  is  by  all  means  the  most  constant  and  is  the  prolonga- 
tion backwards  of  the  posterior  root  of  the  zygoma  over  the 
entrance  of  the  external  auditory  canal.  It  is  the  most  relia- 
ble guide  that  we  have  from  the  exterior  of  the  bone  to 
ascertain  the  level  of  the  floor  of  the  middle  cranial  fossa, 
for  in  the  vast  majority  of  individuals  it  is  placed  imme- 
diately inferior  to  this  plane.  That  is  in  the  majority  of 
cases  in  which  the  post-auricular  operation  is  performed, 
the  fossa  of  the  skull  is  placed  at  a  higher  level  than  the  hori- 
zontal line  through  the  upper  wall  of  the  osseous  external 
canal,  so  that  the  location  of  the  floor  of  the  fossa  is  com- 
monly inferior  to  a  plane  passing  through  the  temporal  ridge. 
From  studies  made  by  various  observers,  the  linea  temporalis 
has  been  found  to  lie  lower  than  the  middle  cerebral  fossa 
in  80  per  cent,  of  cases,  while  in  20  per  cent,  it  is  either 
slightly  higher  or  on  a  level  with  it.  Even  in  the  child  the 
temporal  ridge  is  practically  always  appreciable  and  as  it  is 
so  generally  constant,  it  is  of  most  important  value  in  deter- 
mining the  upper  limits  of  the  operative  field,  as  under  no 
circumstances  should  the  bony  removal  be  carried  above  this 
line  for  fear  of  unnecessarily  entering  the  skull  cavity.  As 
it  is  almost  invariably  present,  and  is  probably  the  most  easily 
recognized  of  all  the  landmarks  here,  its  value  in  a  surgical 
aspect  is  of  course  greatly  enhanced,  and  while  it  may  pre- 
sent slight  anatomical  variations  that  may  cause  it  to  be  on 
a  line  with  the  cranial  floor  or  slightly  above  it,  such  are  very 
rare  and  one  may  feel  perfectly  safe  in  considering  it  as  a 
landmark  that  will  be  a  safe  guide.  In  the  young  child,  the 
prominence  of  this  ridge  is  due  to  the  marked  oblique  angle 
between  the  auditory  plate  and  the  squama,  but  in  some  cases, 
instead  of  the  squamous  portion  of  the  bone  occupying  an 
almost  vertical  position,  it  may  be  considerably  inclined,  and 
thus  form  an  acute  angle  with  the  horizontal  plane,  so  that 


Anatomical  and  Surgical  Landmarks.          217 

the  linea  temporalis  overhangs  the  orifice  to  the  external 
canal,  and  in  operating  may  be  mistaken  for  its  superior 
margin.  To  avoid  this  error,  the  bony  tissues  in  this  region 
should  be  fully  exposed  by  drawing  the  anterior  flap  of  the 
soft  tissues  well  forward  and  the  landmarks  clearly  shown 
before  the  bone  is  at  all  opened,  for  if  this  be  not  done,  and 
the  temporal  ridge  in  this  unusual  situation  cut  away  in  mis- 
take for  the  superior  wall  of  the  meatus,  the  opening  will 
be  superior  to  the  antrum  and  the  chisel  will  enter  the  middle 
cranial  fossa. 

The  venous  relations  of  the  mastoid  and  tympanic  re- 
gions, aside  from  the  lateral  sinus,  present  but  little  of  im- 
portance in  operations  here  for  the  relief  of  chronic  tympanic 
suppuration,  when  the  various  complications  of  mastoiditis 
are  not  considered.  As  it  is  not  desired  to  touch  in  any  way 
upon  these  latter  features,  it  will  therefore  be  unnecessary 
to  occupy  much  space  with  this  part  of  the  subject,  but  it  is 
desired  to  state  that  the  inferior  petrosal  sinus  receives  a 
considerable  number  of  small  venous  branches  from  the  in- 
terior of  the  bone,  and  thus  adds  to  the  dangers  arising  from 
the  transmission  of  infection.  In  addition  to  this,  at  various 
points,  and  especially  at  the  petrosquamous  suture  where 
fibrous  slips  from  the  dura  enter  through  the  minute  osseous 
clefts,  vascular  channels  also  enter  and  form  a  direct  com- 
munication in  this  way,  so  that  the  interior  of  the  mastoid 
and  the  cranial  contents  possess  a  quite  intimate  vascular 
association.  As  regards  the  mastoid  cortex,  one  is  apt  to 
sometimes  have  annoying  bleeding  take  place  when  the  perios- 
teum is  stripped  up  from  the  posterior  surface.  This  results 
from  severing  the  mastoid  emissary  vein,  and  while  in  the 
majority  of  cases  the  vein  is  small  and  of  little  surgical 
importance,  yet  in  a  few  instances  where  the  depression  in 
the  bone  through  which  it  passes  is  quite  large  and  the  vein 
also  correspondingly  increased  in  size,  it  may  produce  con- 
siderable bleeding  and  for  a  time  prove  most  annoying. 


218  Suppuration  of  the  Middle  Ear. 

Of  the  greatest  importance  in  every  mastoid  operation, 
and  that  which  causes  the  greatest  concern  to  the  operator, 
is  the  lateral  sinus  and  its  location  in  relation  to  the  field  of 
operation.  There  is  probably  no  important  portion  of  the 
temporal  bone  which  is  so  uncertain  or  presents  so  many  diffi- 
culties in  determining  its  location  as  this  sinus,  and  in  per- 
forming even  the  simple  mastoid  operation  there  is  no  one 
part  of  the  bone  which  causes  the  operator  greater  concern, 
or  in  which  he  is  less  able  to  formulate  accurate  rules  for  its 
avoidance  than  is  this  sinus.  While  many  suggestions  have 
from  time  to  time  been  offered  so  that  the  operation  may  be 
safely  conducted  as  regards  the  wounding  of  this  vessel,  yet 
they  do  not  possess  a  great  deal  of  value,  and  in  opening  the 
mastoid  process  we  practically  have  no  absolute  guide  that 
may  be  based  upon  the  topography  of  the  parts.  Each  case 
should  therefore  be  conducted  as  if  the  sinus  were  directly 
in  the  position  at  which  it  is  desired  to  enter  the  antrum  and 
the  operation  should  be  performed  with  the  knowledge  that 
the  sinus  may  be  encountered  at  any  step  and  due  precau- 
tions should  be  taken  accordingly.  Not  only  does  it  vary  as 
regards  its  position,  but  as  pointed  out  by  Randall,  it  also 
varies  as  regards  its  size,  and  as  most  of  the  blood  of  the 
superior  longitudinal  sinus  usually  flows  to  the  right,  the 
sinus  of  this  side  is  often  the  larger  and  grooves  more 
broadly  and  deeply,  the  temporal  bone  at  the  sigmoid  sulcus, 
extending  further  forward  and  outward  with  its  stronger 
curves.  This  factor  is  of  no  value,  however,  in  render- 
ing the  operation  safer  on  the  opposite  side  and  he 
further  finds  that  the  space  between  the  sigmoid  sulcus  and 
the  antrum  is  actually  and  relatively  smaller  in  the  adult, 
but  rarely  exceeds  5  millimeters,  while  there  is  a  distance 
of  10  millimeters  between  it  and  the  posterior  wall  of  the 
external  canal.  It  is  usually  considered,  and  a  study  of  a 
large  number  of  temporal  bone  will  show,  that  in  the  normal 


EXPLANATORY    NOTE    TO    PLATE    XXV. 


An  original  anatomical  section  through  the  temporal  bone  exposing  the  inner 
surface  of  the  membrana  tympani  and  ossicles.  The  diploic  character  of  the  mastoid 
process  is  shown. 

i,  Roof  of  tympanum;  2,  ossicles;  3,  membrana  tympani;  4,  facial  canal;  5, 
promontory ;  6,  diploic  cells ;  7,  cerebral  fossa ;  8,  mastoid  antrum ;  9,  aditus  ad 
antrum. 

22O 


PLATE  XXV 


Anatomical  and  Surgical  Landmarks.          221 

mastoid,  when  the  cortex  is  thick,  the  osseous  tissue  is  very 
apt  to  be  thin  over  the  tip  and  in  the  region  of  the  digastric 
fossa,  while  in  other  specimens,  where  the  mastoid  process 
projects  but  little  and  is  small  in  size,  the  lateral  sinus  will 
often  encroach  upon  the  antrum,  but  unfortunately  there  are 
many  exceptions  to  this.  When  the  sinus  is  very  large  and 
bulbous  it  comes  in  closer  contact  with  the  cortex  and  pos- 
terior canal  wall,  and  the  osseous  tissue  covering  it  in  either 
of  these  directions  affords  but  little  protection  when  opera- 
tion is  performed  here,  while  in  the  diploetic  type  of  mastoid 
the  same  conditions  are  very  apt  to  be  present.  When  the 
mastoid  process  is  strongly  developed  and  the  pneumatic 
spaces  well  marked,  there  is  comparatively  little  danger  of 
encountering  the  sinus  during  the  opening  of  the  operative 
tract  from  the  cortex  to  the  antrum.  On  the  other  hand, 
where  the  bone  is  small  and  sclerotic,  there  is  but  a  small 
bridge  of  compact  osseous  tissue  between  the  sinus  and  the 
posterior  canal  wall,  and  when  this  condition  exists  in  con- 
nection with  the  sinus  .placed  well  forward,  it  is  almost  im- 
possible to  avoid  opening  its  osseous  canal  during  operation. 
It  is  sometimes  believed  that  a  prominent  temporal  ridge 
indicates  that  the  sinus  is  placed  further  forward  than  usual, 
but  this  is  so  unreliable  that  it  is  of  no  practical  value. 

In  a  general  way,  the  sinus  may  present  either  one  or  two 
well-marked  abnormalities  as  regards  its  position ;  its  groove 
may  be  unusually  deep,  and  when  this  is  found,  the  enlarge- 
ment of  the  channel  lessens  the  thickness  of  the  osseous  tissue 
separating  it  from  the  wall  of  the  antrum,  or  the  groove  may 
be  placed  much  more  anteriorly  than  usual,  so  that  the  sinus 
is  brought  immediately  internal  to  the  antrum,  or  even  in  rare 
cases  in  front  of  it,  so  that  the  cavity  of  the  antrum  will  be 
narrowed  from  without  inward  and  its  inner  wall  will  assume 
a  more  dangerous  significance  than  if  this  was  not  the  case. 
Normally  the  sinus  lies  behind  the  antrum,  but  in  another 


222  Suppuration  of  the  Middle  Ear. 

small  group  of  cases  the  bend  in  the  sinus  may  be  so  short 
that  an  acute  angle  is  formed,  which  again  brings  it  into 
extremely  close  relation  with  the  canal  wall  and  even  so  near 
the  surface  of  the  mastoid  process  that  it  is  impossible  to 
enter  the  antrum  at  the  usual  point.  The  more  one  ap- 
proaches the  tip  the  less  danger  there  is  of  wounding  the 
sinus,  while  as  a  rule  the  most  dangerous  area  is  placed 
directly  back  of  the  antrum,  but  unfortunately  in  all  these 
variations,  external  measurements  are  of  little  or  no  value 
in  ascertaining  this  in  advance  of  operation,  and  one  must 
always  keep  in  mind  when  operating  here  the  variations  in 
size  and  position  that  may  be  encountered,  so  that  it  is 
advisable  to  make  the  opening  through  the  cortex  of  the 
mastoid  as  near  the  posterior  wall  of  the  external  canal  as 
possible,  as  a  measure  of  precaution,  and  then  after  the  cells 
are  first  entered  one  is  enabled  to  obtain  a  fair  idea  of  the 
relations  of  the  parts,  and  can  then  enlarge  the  field  of  oper- 
ation to  the  size  required  with  a  considerable  degree  of 
safety.  That  the  sinus  may  present  such  serious  variations 
is  well  shown  in  a  case  reported  by  Powers,  in  which,  during 
the  first  step  of  the  operation,  it  was  encountered,  and  the 
operation  had  to  be  abandoned.  The  autopsy  later  showed 
that  the  sigmoid  sulcus,  instead  of  turning  sharply  and  form- 
ing only  a  slight  groove  between  the  pars  petrosa  and  the 
squama,  extended  so  far  ventralwards  that  with  the  exception 
of  a  slight  bridge  of  bone  in  the  anterior  aspect  of  the  ante- 
rior pyramid,  these  two  portions  were  completely  separated 
and  the  sinus  extended  above  the  mastoid  crest  for  some  0.7 
centimeter  ventralward  to  the  external  auditory  meatus  and 
caudal  ward  to  a  point  within  0.7  centimeter  from  the  tip 
of  the  mastoid.  In  opposition  to  this  view  of  the  changes 
in  the  position  of  the  sinus  rendering  it  so  liable  to  injury 
during  the  performance  of  the  mastoid  operation,  Hart- 
mann  in  one  hundred  preparations  only  found  two  in  which 


Anatomical  and  Surgical  Landmarks.          223 

trephining  would  injure  the  sinus,  while  Ricord  found  only 
one  case  in  which  this  danger  existed,  and  in  what  he  calls 
an  "extreme  case,"  a  distance  of  12  millimeters  still  sepa- 
rated the  sinus  from  the  posterior  wall  of  the  external  meatus 
and  he  further  concludes  that  the  posterior  half  of  the  mas- 
toid  is  dangerous  on  account  of  its  vicinity  to  the  lateral 
sinus,  but  the  danger  diminishes  in  proportion  as  one  leaves 
the  base  to  approach  the  summit  of  the  process. 

Of  the  various  theories  that  have  been  advanced  to  deter- 
mine the  location  of  the  sinus  previous  to  operation,  it  has 
been  suggested  that  it  can  be  accurately  located  by  applying 
a  tuning  fork  and  stethoscope  to  the  temporal  bone.  With 
the  bell  of  the  stethoscope  placed  over  the  mastoid  process, 
the  handle  of  a  vibrating  tuning  fork  is  placed  against  the 
head  one  inch  behind  the  mastoid  and  the  fork  is  gradually 
moved  closer  to  the  stethoscope,  so  that  a$  soon  as  the  border 
of  the  mastoid  is  reached  a  decided  increase  in  the  volume 
of  the  fork  takes  place.  Like  various  other  methods  for 
determining  the  site  of  the  sinus,  this  method  unfortunately 
has  proven  of  little  value,  and  cannot  in  any  way  be  de- 
pended upon.  Amberg,  in  studying  this  highly  important 
question,  states  that  displacement  of  the  lateral  sinus  is  due 
to  and  indicated  by  asymmetry  of  the  skull.  No  skull  is 
entirely  symmetrical,  the  -right  side  as  a  rule  being  smaller 
than  the  left,  and  as  on  the  smaller  side  the  sinus  is  dis- 
placed forward,  so  the  sinus  is  displaced  more  frequently 
on  the  right  side.  He  gives  the  following  signs  to  indicate 
that  the  sinus  is  displaced  forward :  ( I )  The  eye  is  somewhat 
higher  on  the  side  on  which  the  sinus  is  displaced.  (2)  The 
nasal  septum  is  pushed  towards  the  opposite  side;  there  is  a 
prominence  on  the  opposite  side ;  the  tip  of  the  nose  is  turned 
towards  the  side  on  which  the  sinus  is  forward  and  the  aper- 
ture pyriformis  is  larger  and  stands  somewhat  higher  on  the 
same  side.  (3)  The  hard  palate  on  the  same  side  is  higher 


224  Suppuration  of  the  Middle  Ear. 

and  narrower.  (4)  The  incisor  is  placed  a  little  more 
towards  the  side  on  which  the  sinus  is  displaced  forwards. 
(5)  The  occipital  and  parietal  bones  are  pressed  inwards  on 
the  same  side  and  pushed  outwards  on  the  opposite  side.  (6) 
The  greater  the  extent  of  the  planum  mastoideum  and  the 
more  perpendicular  it  stands  on  the  outer  meatus,  the  less 
strongly  the  sinus  is  developed.  The  planum  forms  an 
angle  greater  than  a  right  angle  with  the  meatus.  In  seven- 
teen bones  he  found  the  thickness  of  the  wall  of  the  sinus  to 
vary  from  2.5  to  10  millimeters,  with  an  average  thickness 
of  5.75  millimeters. 

As  the  topography  of  the  temporal  bone  and  its  land- 
marks vary  to  a  considerable  extent  in  the  child  from  that 
of  the  adult  bone,  it  is  essential  to  bear  in  mind  these  varia- 
tions when  operating  in  the  young,  as  they  influence  not  only 
the  direct  method  of  opening  the  mastoid,  but  also  the  patho- 
logical changes  which  take  place  here  following  chronic  sup- 
purative  changes  in  the  tympanic  cavity.  As  with  the  adult, 
the  depth  of  the  middle  cranial  fossa  of  course  varies,  but 
even  in  the  child  one  can  always  be  positive  that  it  lies  above 
the  supramastoid  spine.  At  birth  the  external  wall  of  the 
epitympanic  space  is  in  the  same  position  as  occupied  by  the 
inferior  wall  in  the  adult,  the  variations  at  this  point  result- 
ing from  the  changes  assumed  by  the  direction  of  the  pars 
squamosa  during  the  developmental  period.  As  a  result  of 
this,  the  vault  of  the  tympanic  cavity  is  readily  entered  imme- 
diately above  the  superior  attachment  of  the  membrana  tym- 
pani,  but  in  making  the  incision  through  the  superficial  soft 
tissues  in  performing  any  post-auricular  operation  at  an 
early  age,  great  care  must  be  taken  not  to  make  too  much 
pressure,  as  the  knife  may  pass  through  the  squamous  suture 
into  the  cranial  cavity,  as  this  suture  does  not  become  closed 
completely  until  a  later  period,  and  always  presents  a  large 
opening  in  the  osseous  structure  which  is  filled  with  soft 


'Anatomical  and  Surgical  Landmarks.          225 

fibro-cartilage.  For  the  same  reasons  gentleness  should 
always  be  exercised  even  in  laying  back  the  integument  and 
periosteum  in  making  the  anterior  flap.  The  "spongy  spot," 
which  has  previously  been  mentioned  and  which  is  present 
in  all  young  children,  is  situated  over  the  exact  level  of  the 
antrum,  but  at  birth  it  is  somewhat  above  this  level,  then 
later  it  becomes  above  and  in  front,  so  at  a  still  later  period 
this  vascular  area  is  in  relation  posteriorly  with  the  supra- 
meatal  spine,  and  when  this  relationship  becomes  well  marked 
the  spina  becomes  valuable  as  a  landmark  of  surgical  im- 
portance. When  one  removes  the  cortex  at  this  level,  that 
is,  over  the  area  above  and  behind  the  external  meatus,  the 
antrum  is  very  rapidly  reached  and  in  the  first  two  years  of 
life  it  is  situated  but  a  slight  distance  beneath  the  surface, 
so  that  the  slightest  pressure  with  the  instrument  employed 
over  the  perforated  vascular  area  immediately  above  it  will 
show  the  antrum  at  once.  Both  in  the  child  as  well  as  in 
the  adult  it  is  never  advisable  to  remove  the  mastoid  cortex 
as  a  primary  step  of  th«  operation  at  a  higher  level  than  the 
spine  of  Henle,  and  in  order  to  remain  within  the  zone  of 
safety,  it  is  always  essential  to  enter  the  mastoid  just  pos- 
terior and  close  to  this  spine,  so  that  the  antrum  will  be  en- 
tered with  a  minimum  of  danger,  and  then  if  it  is  desired  to 
expose  the  attic  of  the  tympanum,  the  external  table  may 
readily  be  removed  in  a  forward  and  upward  direction.  As 
the  osseous  auditory  canal  is  not  present  at  an  early  age, 
it  is  necessary  to  bear  in  mind  that  the  squamous  plate 
occupies  a  much  more  horizontal  position,  and  that  the 
fibrous  canal  is  thus  attached  to  its  outer  aspect  at  a  dif- 
ferent angle  than  that  which  is  seen  as  the  child  becomes 
older,  or  as  adult  life  is  reached  (see  plates  XXII  and 
XXIII).  As  a  result  of  the  canal  being  attached  to  the 
squama  along  its  superior  aspect,  the  attachment  of  the 
auricle  to  the  bone  is  situated  at  a  much  higher  level  than 
the  tympanic  membrane,  so  that  in  cases  where  it  is  desired 

16 


226  Suppuration  of  the  Middle  Ear. 

to  detach  the  auricle,  the  superior  pole  of  the  line  of  in- 
cision will  be  at  a  higher  level  than  the  annulus  tympan- 
icus.  In  those  cases  at  an  early  age  where  the  anterior 
flap  is  drawn  well  forward,  the  extremely  firm  attachment 
of  the  soft  tissues  of  the  meatus  above  and  behind  is  apt  to 
lead  the  operator  into  error  in  believing  that  the  margin  of 
the  annulus  has  been  exposed  and  if  the  opening  be  made  in 
the  mastoid  under  these  conditions  without  the  posterior  por- 
tion of  the  ring  being  seen  and  the  location  of  the  spina  not 
definitely  ascertained,  it  is  perfectly  possible  that  instead  of 
the  opening  entering  the  mastoid  in  the  direction  of  the 
antrum,  it  will  enter  instead  into  the  middle  cranial  fossa. 
In  order  therefore  to  avoid  this  very  serious  error,  it  is  abso- 
lutely essential  that  these  attachments  of  the  auricle  should 
be  thoroughly  separated  from  this  portion  of  the  temporal 
bone  until  the  spina  is  well  defined  and  it  can  be  seen  that 
the  external  canal  fades  away  into  the  membrana  tympani, 
and  in  order  to  better'  ascertain  this  latter  point,  it  is  always 
well  to  make  an  incision  into  the  fibrous  canal  so  that  the 
tympanic  membrane  can  be  clearly  seen. 

Going  back  to  the  adult  again,  the  external  landmarks 
do  not  become  altered  as  a  result  of  sclerosis  producing  the 
eburnated  type  of  mastoid.  When  such  a  type  of  mastoid 
is  encountered,  the  usual  opening  if  allowed  to  continue  for 
any  depth  is  fairly  sure  to  strike  the  sinus,  or  if  this  is  fortu- 
nately not  the  case,  the  further  penetration,  unless  great  care 
can  be  taken,  will  result  in  the  opening  of  the  middle  cranial 
fossa.  It  should  therefore  invariably  be  made  the  rule  under 
these  conditions  to  remove  the  bone  in  but  thin  layers,  and 
after  the  cortex  has  been  sufficiently  opened,  to  accurately 
measure  the  distance  inwards  at  frequent  intervals,  to  use 
the  probe  almost  constantly,  and  to  hug  the  posterior  wall 
of  the  auditory  canal  as  closely  as  possible;  in  this  way  the 
dangers  are  reduced  to  a  minimum  and  the  antrum  can 
usually  be  reached. 


CHAPTER  II. 

PRELIMINARY  PREPARATION  OF  THE 
PATIENT  FOR  OPERATION. 


227 


PRELIMINARY  PREPARATION  OF  THE  PATIENT  FOR 
OPERATION. 

The  preparation  of  the  patient  for  operation,  as  regards 
his  general  condition  does  not  differ  in  any  essential  re- 
spects from  the  preparation  for  operations  of  like  magnitude 
in  any  other  portion  of  the  body,  and  it  is  therefore  useless 
to  describe  here  what  is  already  so  well  known.  However, 
it  is  desired  to  emphasize  a  few  important  points  in  this  con- 
nection and  especially  that  'it  is  advisable  to  have  the  patient 
in  as  good  a  physical  condition  at  the  time  of  operation  as 
is  possible,  although  in  many  cases  this  cannot  always  be 
obtained,  and  the  mastoid  must  be  opened  with  the  .patient 
often  septic  and  ill  fitted  to  stand  the  necessary  operative  pro- 
cedures. As  a  rule  it  is  advisable  to  keep  the  patient  in  bed 
the  day  previous  to  operation,  to  restrict  the  diet  and  under 
such  conditions  it  is  always  advisable  to  have  the  bowels 
thoroughly  moved.  The  well-known  injunction  to  avoid 
food  for  a  number  of  hours  before  operation  should  also  be 
remembered.  As  the  hair  is  the  most  common  source  from 
which  the  superficial  skin  wound  may  become  infected,  it  is 

absolutely  essential  that  the  scalp  should  be  shaven  in  part 

229 


230  Suppuration  of  the  Middle  Ear. 

or  whole  as  may  seem  necessary  in  the  particular  case.  This 
should  be  done  several  hours  previous  to  operation,  and  pref- 
erably the  day  before,  while  the  hair  removed  should  include 
not  only  the  beard,  if  the  patient  be  a  male,  but  also  an  area 
extending  from  three  to  five  inches  above  and  behind  the 
auricle.  This  should  be  closely  shaven  in  both  sexes,  while 
some  operators  prefer,  and  it  undoubtedly  is  safest,  to  shave 
the  entire  scalp  in  males.  After  shaving  the  head  and  pre- 
liminary to  operation,  the  tissues  should  be  rendered  as  aseptic 
as  possible  in  various  ways,  depending  to  a  great  extent  upon 
the  choice  of  the  operator.  Irrespective  of  whatever  anti- 
septic solutions  may  be  employed  for  this  purpose,  the  parts 
should  always  be  thoroughly  scrubbed  with  soap  and  hot 
sterile  water,  and  if  not  unduly  sensitive,  a  small  brush  should 
be  employed  for  this  purpose.  Not  only  should  the  parts 
that  have  been  shaven  be  cleansed  in  this  manner,  but  the 
entire  head,  neck  and  auricle  should  also  be  rendered  as  sur- 
gically clean  as  possible,  and  while  many  of  the  liquid  soaps 
prepared  for  this  purpose  will  be  found  satisfactory,  yet  the 
older  tincture  of  green  soap  or  the  ethereal  liquid  soap  are 
especially  efficacious.  Following  this,  the  parts  should  be 
cleansed  of  the  remains  of  the  soap  by  washing  with  a  warm, 
sterile  saline  solution,  and  then  the  areas  which  have  been 
shaven,  or  if  the  hair  has  been  removed  from  the  entire  head, 
the  tissues  over  the  temporal  bone  and  adjacent  to  it  should 
be  mopped  with  turpentine  or  ether  to  remove  any  fatty 
matter  from  the  skin.  Alcohol  in  the  strength  of  95  per 
cent,  is  then  used  for  cleansing,  and  following  this  a  I  to 
looo  bichloride  of  mercury  solution  or  a  weak  solution  of 
carbolic  acid  is  applied  in  the  same  manner.  Previous  to 
this,  or  following  it,  the  former,  however,  being  preferable, 
the  external  auditory  canal  should  be  thoroughly  cleansed, 
and  while  the  tissues  in  part  here  are  already  infected,  yet  it  is 
essential  that  the  most  painstaking  antiseptic  precautions  be 


Preparation  of  the  Patient  for  Operation.      231 

taken,  so  that  as  much  as  possible  of  the  infective  material 
already  present  should  be  removed,  and  also  in  order  to  pre- 
vent further  infection  by  micro-organisms  which  may  be 
even  more  serious  than  those  already  present.  A  syringe 
should  be  used  for  this  purpose  and  the  canal  washed  out 
with  a  i  to  5000  formaline  solution,  or  a  I  to  5000  bichloride 
of  mercury  solution;  in  some  cases,  where  the  purulent  dis- 
charge is  unusually  offensive,  a  stronger  solution  of  bichloride 
may  be  employed,  such  as  I  to  1000  strength,  and  then  the 
canal  should  be  thoroughly  scrubbed  with  sterile  cotton  satu- 
rated with  peroxide  of  hydrogen.  If  convenient  the  cleans- 
ing of  the  canal  should  be  performed  daily  for  several  days 
preceding  operation,  and  at  the  final  cleansing,  as  outlined, 
the  entire  canal  should  be  lightly  dusted  with  an  antiseptic 
powder,  such  as  iodoform  and  the  canal  occluded  with  sterile 
or  iodoform  gauze.  Over  the  auricle  and  the  entire  side  of 
the  head,  which  has  been  rendered  antiseptic,  a  plain  bichlo- 
ride or  carbolic  dressing  is  then  applied,  and  this  in  turn  is 
kept  in  place  with  a  bandage  until  it  is  removed  at  the  time 
of  operation.  If  possible  the  parts  should  be  cleansed  as 
here  described  the  day  previous  to  the  operation,  but  if  this 
is  not  possible  it  should  be  done  at  least  several  hours  in 
advance. 

In  cases  where  there  are  any  purulent  changes  in  the 
nasal  chambers,  such  as  sinusitis,  or  the  patient  is  suffering 
from  ozoena,  these  parts  should  be  cleansed  with  an  alkaline, 
antiseptic  solution.  It  is  unnecessary  to  here  give  details  as 
to  the  methods  of  sterilizing  the  hands  of  the  operator  and  his 
assistants,  and  the  care  taken  in  this  respect  to  avoid  infec- 
tion, as  these  points  are  given  in  every  text-book  and  differ 
in  no  way -from  such  preparation  as  are  made  in  the  perform- 
ance of  general  surgical  procedures  elsewhere.  The  ques- 
tion of  wearing  gloves  either  of  cotton  or  rubber  has  not  as 
yet  been  considered  to  any  great  extent  in  aural  operations 


232  Suppuration  of  the  Middle  Ear. 

as  in  general  surgery  and  while  in  chronic  suppurative  otitis 
media  the  tissues  in  part  at  least  already  contain  pus,  it  would 
seem  that  thorough  sterilization  of  the  hands  by  any  of  the 
methods  commonly  in  use  would  be  sufficient,  but  where  there 
is  especial  danger  of  entering  the  cranial  cavity  or  of  acci- 
dentally opening  the  lateral  sinus,  one  would  certainly  be 
more  secure  in  wearing  sterile  gloves  than  if  such  were  not 
the  case.  At  the  present  time,  however,  they  would  appear  to 
be  a  refinement  that  are  not  necessarily  of  service  in  all  cases. 
Some  mention  may  be  made  here  as  regards  the  sterilization 
of  the  instruments  and  dressings,  all  the  larger  instruments, 
with  the  exception  of  those  with  a  cutting  edge,  should  be 
boiled  in  a  2  per  cent,  soda  solution  for  at  least  ten  or  fifteen 
minutes  and  then,  when  ready  for  use,  transferred  to  pans 
of  sterile  water.  Knives,  of  course,  cannot  be  sterilized  in 
this  way  for  fear  of  damaging  them,  but  they  may  be  placed 
in  the  hot  soda  solution  for  one  or  two  minutes  and  then 
washed  with  alcohol,  or  may  be  rendered  perfectly  sterile  by 
placing  them  in  formaline  vapor  for  a  time,  all  the  dress- 
ings being  rendered  sterile,  both  those  which  are  applied 
after  the  preliminary  cleansing  already  described  and  those 
used  after  the  operation  has  been  performed. 

At  the  time  of  the  operation,  after  the  patient  has  been 
anaesthetized,  the  antiseptic  dressings,  which  have  been  left 
undisturbed,  are  then  removed  and  the  tissues  again  thor- 
oughly cleansed.  At  this  time  the  external  canal  should  first 
receive  attention  by  removing  the  gauze  plug  at  the  meatus 
and  syringing  with  a  saturated  boric  acid  solution  or  a  i  to 
5000  bichloride  of  mercury  solution,  when  the  meatus  is  for 
a  time  occluded  with  gauze  or  not  as  may  be  desired.  The 
field  of  operation,  including  the  neck  and  auricle  are  then 
washed  with  alcohol  or  ether  and  this  is  followed  by  a  I  to 
looo  bichloride  solution,  with  which  the  parts  should  again 
be  thoroughly  scrubbed.  If  the  entire  head  has  not  been 


Preparation  of  the  Patient  for  Operation.      233 

shaved,  the  hair  should  be  covered  with  gauze  bandages, 
either  sterile  or  wrung  out  in  a  bichloride  solution,  while  if 
the  patient  is  a  female,  an  antiseptic  starch  bandage  may  be 
used  to  keep  the  hair  in  place,  or  if  preferred,  a  sterile  rubber 
cap  may  be  employed  for  the  same  purpose.  The  rest  of 
the  head,  neck  and  adjacent  regions  should  then  be  protected 
either  with  dry  sterile  gauze,  or  sublimated  compresses,  or 
towels  wet  with  the  bichloride  solution  may  be  employed. 


CHAPTER  III. 

THE  SIMPLE  MASTOID  OPERATION, 


235 


THE  SIMPLE  MASTOID  OPERATION. 

The  question  of  partial  or  complete  failure  to  cure  chronic 
suppurative  otitis  media  after  operation  through  the  external 
canal,  resolves  itself  into  the  fact  that  all  the  carious  and 
necrosed  tissue  has  not  been  removed,  and  this  may  be  readily 
explained  by  the  pathology  of  tympanic  suppuration  whereby 
in  the  great  majority  of  chronic  cases  the  antrum  and  mas- 
toid  cells  are  involved  at  a  fairly  early  stage,  and  cure  of 
necessity  becomes  impossible  until  all  this  diseased  tissue  is 
also  removed  by  operative  procedure.  Both  the  location  of 
the  mastoid  process  in  relation  to  the  tympanic  cavity  and 
its  histological  structure  are  favorable  to  this  extension  of 
the  inflammatory  process,  and  as  has  been  shown  by  many 
otologists,  the  antrum  plays  the  part  of  a  "drip  cup,"  so  that 
when  the  patient  is  in  a  recumbent  position,  the  pus  flows 
backward  from  the  middle  ear,  it  thus  becoming  impossible 
to  effect  a  favorable  result  in  such  cases  without  opening  the 
mastoid.  In  later  stages,  the  pathological  changes  may  even 
be  more  marked  here  than  in  the  tympanum,  so  that  from 
various  causes  acute  exacerbations  taking  place,  the  chronic 
suppuration  for  a  time  assumes  all  the  features  of  an  acute 

237 


238  Suppuration  of  the  Middle  Ear. 

mastoiditis,  or,  on  the  other  hand,  the  symptoms  may  result 
from  the  retention  of  pus  in  the  mastoid  interior.  As  the 
cells  of  the  mastoid  are  lined  with  the  continuation  of  the 
tympanic  muco-periosteum,  it  is  not  difficult  to  appreciate  the 
sequence  of  changes,  such  as  the  simple  inflammation,  then 
necrosis  of  the  mucosa,  with  a  periostitis,  osteitis  and  finally 
caries.  To  a  great  extent,  however,  the  character  and  area 
involved,  depends  upon  the  anatomical  variety  of  the  mas- 
toid, as  for  example  the  pneumatic  type  is  more  frequently 
involved  than  the  diploic,  and  the  vertical  portion  of  the 
compact  process  remains  uninvolved,  even  though  the  process 
be  extensive  (see  plates  XXIV  and  XXV).  In  some  cases 
these  changes  will  hardly  be  in  evidence  in  the  portion  of  the 
mastoid  where  such  would  be  expected,  but  a  pus-filled  cell 
in  the  tip  will  be  the  major  focus,  the  rationale  of  the  mas- 
toid changes  in  great  part  being  shown  by  the  peculiar 
placing  of  the  mucous  folds  or  bands  in  the  antrum  and  its 
immediate  vicinity,  which,  extending  into  the  adjacent  mas- 
toid cells,  do  not  in  the  normal  condition  interfere  with  the 
drainage  of  these,  parts,  but  when  it  becomes  infiltrated  as 
the  result  of  the  tympanic  suppuration,  the  drainage  becomes 
inefficient  or  entirely  abolished,  and  the  resultant  purulent 
changes  in  the  mastoid  produce  the  empyema  found  here. 

The  object,  therefore,  of  the  simple  mastoid  operation, 
is  to  effect  a  communication  with  the  antrum  through  the 
mastoid  process  in  order  that  efficient  drainage  may  be 
obtained.  Before  further  elaborating  this  statement,  it  may 
be  well  to  state  that  the  simple  opening  of  the  mastoid  process 
without  entering  the  antrum,  has  no  place  at  all  in  the  treat- 
ment of  chronic  aural  suppuration,  and  that  even  the  mere 
opening  of  the  mastoid  itself  is  of  little  value  in  this  con- 
dition unless  the  diseased  tissue  be  removed.  It  is  there- 
fore implied  when  using  the  term  "the  simple  mastoid 
operation"  here,  that  it  is  but  the  basis  of  the  radical 


The  Simple  Mastoid  Operation.  239 

operation,  and  as  will  be  seen  further,  is  applicable  in  those 
cases  where  the  mastoid  is  not  extensively  involved  and 
the  involved  areas  may  be  removed  through  the  opening 
in  the  cortex,  without  throwing  open  into  one  large  cavity 
the  tympanic  cavity,  attic,  antrum  and  mastoid,  as  is  done 
in  the  so-called  radical  operation,  which  is  not  necessary 
for  the  cure  of  all  cases  of  chronic  suppurative  otitis.  It 
is  impossible  for  the  surgeon  to  know  in  advance  of  opera- 
tion the  amount  of  tissue  destruction  present,  so  it  is  advis- 
able to  always  open  the  antrum  as  a  primary  procedure  and 
then  proceed  as  may  be  indicated  by  the  conditions  present, 
so  that  drainage  may  be  effected  through  the  antrum  into 
the  tympanum  and  that  healing  may  take  place  from  within 
outwards.  In  order  to  accomplish  this,  it  should  be  the 
object  of  this  operation  to  break  down  all  the  bony  lamina 
separating  the  cells  from  the  antrum  and  from  the  exterior, 
so  that  a  single  cavity  is  made  and  the  communication  be- 
tween the  antrum  and  tympanum,  which  is  usually  narrowed 
by  granulation  tissue,  is  freely  opened  for  drainage.  This 
is  the  so-called  Schwartze  operation  in  distinction  to  the 
radical  operation  which  goes  by  a  number  of  titles,  depend- 
ing upon  its  modification,  and  which  comprises  the  exen- 
teration  of  both  the  tympanum  and  mastoid.  While  a  few 
radical  otologists  state  that  the  Schwartze  operation  is  indi- 
cated only  in  acute  mastoid  abscess  and  is  not  adapted  for  the 
surgical  treatment  of  the  condition  under  consideration,  yet 
this,  in  the  opinion  of  the  writer,  is  not  the  case,  as  this  oper- 
ation will  in  a  number  of  cases  be  followed  by  successful 
results  and  further  it  forms  the  basis  of  all  mastoid  opera- 
tions in  which  the  opening  is  made  through  the  cortex  in  con- 
tradistinction to  Stacke's  operation.  Schwartze's  method 
representing  an  operative  procedure,  which  may  be  modified 
to  fulfill  the  requirements  indicated,  up  to  the  complete  rad- 
ical operation. 


240  Suppuration  of  the  Middle  Ear. 

Probably  the  most  difficult  problem  in  chronic  suppura- 
tive  otitis  media  at  the  present  time  is  to  know  when  to  open 
the  mastoid  in  the  absence  of  any  well-marked  symptoms 
pointing  to  its  involvement,  and  while  general  indications 
may  be  formulated,  the  question  as  regards  the  individual 
case  must  be  solved  by  the  particular  conditions  present  in 
that  case.  In  general,  irrespective  of  the  operation  to  be 
performed  upon  the  mastoid  process,  the  indications  for 
operation,  as  laid  down  by  Politzer,  are  of  great  value  and 
it  is  desired  to  indicate  some  of  them  here,  both  as  a  basis  for 
indicating  when,  as  far  as  possible,  the  simple  Schwartze 
operation  should  be  performed,  and  as  being  of  value  in 
making  clear  the  reasons  for  the  various  operative  pro- 
cedures to  be  further  described.  He  divides  these  indica- 
tions for  operation  into  two  classes,  subjective  and  objective. 
The  subjective  are  the  persistence  of  pain  in  the  ear  or 
over  the  mastoid  process ;  permanent  or  intermittent  attacks 
of  vertigo  due  to  erosion  of  the  external  semicircular  canal ; 
and  marked  cerebral  disturbance.  The  objective  symptoms 
are:  (i)  Caries  of  the  wall  of  the  tympanum.  (2)  Gran- 
ulations and  polypi  in  the  vicinity  of  the  aditus  and  recur- 
ring quickly  after  removal.  (3)  Fistulous  openings  in  the 
cortex.  (4)  Cholesteatoma.  (5)  Hyperostotic  stricture  of 
the  external  auditory  canal.  (6)  Facial  paralysis  or  paresis. 
(7)  Painful  swelling  of  the  mastoid.  (8)  Prolonged  fcetid 
suppuration  resisting  treatment,  especially  if  the  upper  pos- 
terior region  of  the  membrani  tympani  is  perforated  and 
its  remnants  are  adherent  to  the  internal  wall  of  the  drum 
cavity,  and  more  so  if  pus  and  epithelial  masses  can  be 
drawn  from  the  region  of  the  aditus  by  aspiration.  (9) 
Symptoms  of  tuberculosis  occurring  in  a  case  of  chronic 
suppuration  (aural  suppuration  in  a  case  with  pulmonary 
tuberculosis  being  a  contraindication  for  operation  on  the 
mastoid).  (10)  Evidences  of  intracranial  or  sinus  involve- 


The  Simple  Mastoid  Operation.  241 

ment.  He  further  believes  that  when  the  objective  signs  are 
accompanied  by  some  of  the  more  serious  subjective  signs, 
operation  becomes  imperative.  But  the  clinical  symptoms 
do  not,  however,  always  correspond  to  the  pathological  find- 
ings, as  we  may  find  a  small  amount  of  granulation  tissue 
or  pus  in  the  antrum  with  alarming  symptoms,  or  grave  path- 
ological changes,  with  but  few  symptoms.  So  that  this 
makes  it  impossible  to  lay  down  strict  rules  of  the  indications 
for  operation,  although  he  believes  that  the  mastoid  opera- 
tion is  not  justifiable  in  ordinary  chronic  suppurative  cases, 
until  it  has  been  proven  that  conservative  treatment  will 
not  cure. 

Many  of  these  indications  will  most  strongly  militate 
against  the  simple  mastoid  opening  as  being  insufficient  to 
be  of  any  value,  the  class  of  cases  in  which  this  oper- 
ation is  specially  indicated  being  those  in  which  the  symp- 
toms, both  subjective  and  objective,  indicate  the  limitation 
of  the  morbid  process  to  the  antrum  and  its  immediate  neigh- 
borhood towards  the  mastoid  cortex,  and  in  which  serious 
symptoms,  such  as  facial  paralysis,  vertigo,  intracranial  in- 
volvement or  sinus  changes,  are  not  present.  From  a  purely 
pathological  aspect,  one  should  choose  the  radical  operation 
if  the  symptoms  show  the  temporal  bone  to  be  extensively 
involved,  and  especially  if  cholesteatoma  be  present,  as  under 
no  circumstances  should  the  simple  operation  be  performed 
when  the  latter  condition  is  found  to  exist.  Milligan  states 
that  when  the  suppuration  has  persisted  for  twelve  months, 
with  careful  local  treatment  for  three  months  with  no  avail, 
the  mastoid  antrum  and  contiguous  cells  should  be  opened 
and  cleaned  out,  the  form  of  operation,  whether  Schwartze, 
Stacke,  or  a  modification,  depending  on  the  peculiarity  of 
each  case.  Luc  gives  the  indications  for  opening  the  mas- 
toid when  it  is  desired  to  give  vent  to  pus  in  retention;  to 
circumvent  conditions  indicating  threatening  or  the  com- 

17 


242  Suppuration  of  the  Middle  Ear. 

mencement  of  intracranial  infection,  and  for  the  cure  of  the 
aural  suppuration  after  operation  by  way  of  the  meatus  has 
failed.  Schwartze  believes  these  indications  to  be :  ( i )  Re- 
current inflammation  of  the  mastoid  which  constantly  reap- 
pears, this  indication  being  strengthened  when  there  is  a 
fistula  or  the  burrowing  of  pus.  (2)  When  the  exterior  of 
the  mastoid  is  healthy,  but  there  is  evidence  of  inflammatory 
retention  in  the  middle  ear.  (3)  As  a  prophylactic  opera- 
tion to  facilitate  drainage  in  incurable  foetid  suppuration, 
even  with  no  evidence  of  retention.  While  Macewan  states 
that,  as  a  general  rule,  when  pyogenic  lesions  exist  in  the 
middle  ear  or  its  adnexa,  which  are  either  not  accessible  or 
cannot  be  eradicated  through  the  canal,  the  mastoid  cells 
and  antrum  should  be  opened,  these  cases  being  divided 
into  two  classes:  those  in  which  the  patient's  life  is,  or  is 
believed  to  be,  in  immediate  danger,  and  a  second  class  in 
which  the  principal  object  is  to  remove  the  cause  of  the 
suppuration,  to  improve  the  present  condition,  and  to  relieve 
the  patient  from  the  danger  of  future  complications. 

The  operation  under  particular  consideration  is  indi- 
cated in  that  class  of  cases  in  which  the  pus  in  the  pneumatic 
cells  in  the  location  previously  pointed  out  is  represented  by 
a  localized  empyema,  but  not  in  those  cases  where  there  is 
marked  suppuration  of  a  diploic  mastoid  or  serious  inflam- 
mation of  the  cortical  substance.  In  other  words,  it  is  indi- 
cated where  the  hearing  on  the  affected  side  is  fairly  well 
preserved,  and  where  the  tympanic  suppuration  has  resisted 
local  treatment  and  intratympanic  operation,  but  in  which 
mastoid  symptoms  are  not  in  evidence.  The  involvement  of 
the  mastoid  from  the  suppurative  process  in  the  tympanic  cav- 
ity is  practically  an  essential  part  of  the  pyogenic  process,  but 
it  is  also  influenced  and  enhanced  by  various  factors  which 
prevent  the  free  discharge  of  pus  from  the  tympanic  cavity, 
and  thus  aid  in  its  retention,  with  consequent  stagnation  and 


The  Simple  Mastoid  Operation.  243 

decomposition.  Especially  is  this  evident  when  these  changes 
take  place  in  the  mastoid  process,  so  that  caries  and  necrosis 
ultimately  results  with  absorption  or  destruction  of  the  bone 
substance,  the  most  prominent  factors  concerned  in  these 
changes  being  a  narrowing  or  stenosis  of  the  external  audi- 
tory canal  and  the  more  or  less  complete  obliteration  of  the 
tympanic  cavity  by  granulation  tissue,  polypi  or  cholesteato- 
matous  masses,  these  conditions  often  being  evinced  when 
the  membrana  tympani  is  not  destroyed  by  a  perforation  at 
the  margin  of  its  postero-superior  quadrant  and  suppura- 
tion in  the  epitympanic  space  with  a  perforation  in  Shrap- 
nell's  membrane. 

While  general  anaesthesia  is  practically  always  necessary 
in  the  performance  of  mastoid  operations,  yet  Alexander 
has  reported  several  cases  where  for  various  reasons  this 
was  inadvisable  and  Schleich's  local  anaesthesia  was  used. 
In  some  of  the  cases  the  operation  was  quite  extensive,  and 
in  order  to  diminish  the  shock  and  the  sound  of  the  hammer 
used  in  striking  the  chisel,  the  head  of  the  same  was  cov- 
ered with  muslin.  While  the  local  anaesthesia  was  not  abso- 
lute, it  was  sufficient  to  ensure  comfort,  and  there  were  no 
dangerous  symptoms  or  unpleasant  sequelae,  although  in 
some  of  the  cases  the  operation  lasted  longer  than  an  hour. 
The  solution  that  was  used  for  this  purpose  consisted  of 
one  grain  of  cocaine  to  the  ounce  of  distilled  water.  While 
in  extremely  rare  cases  local  anaesthesia  may  be  employed, 
yet  at  the  present  time  one  would  hesitate  to  relieve  the  pain 
of  the  operation  in  this  very  uncertain  manner,  and  it  may 
be  laid  down  as  a  rule  that  general  anaesthesia  should  be 
employed  in  all  cases  where  the  mastoid  operation  is  per- 
formed, either  in  the  simple  opening  of  the  antrum  or  in  any 
of  the  so-called  radical  procedures. 

After  the  patient  has  been  anaesthetized,  the  original 
dressings  removed  and  the  field  of  operation  again  rendered 


244  Suppuration  of  the  Middle  Ear. 

sterile,  the  first  step  in  this  operation  is  the  primary  incision 
(see  plate  XXVI)  over  the  mastoid  process.  Both  the  loca- 
tion and  extent  of  the  incision  varies  considerably  with  the 
particular  practice  of  the  operator  and  the  extent  of  the  dis- 
eased process  if  evidences  of  such  be  present  upon  the  skin  of 
the  mastoid.  As  a  rule  it  is  advisable  to  begin  the  incision 
well  up  at  a  point  nearly  corresponding  to  the  top  of  the  auri- 
cle or  slightly  above  the  meatus ;  this  cut  should  be  somewhat 
curved  in  outline  and  at  first  it  should  be  carried  slightly 
backwards  in  a  semi-horizontal  direction,  and  then  extend- 
ing vertically,  it  should  extend  as  far  down  as  the  tip  of  the 
mastoid  process.  Again,  in  other  cases,  the  post-auricular 
incision  may  be  made  parallel  to  the  auricle,  and  commencing 
above,  at,  or  about  the  centre  of  the  mastoid,  may  extend 
to  slightly  above  its  base,  and  if  the  space  obtained  by  this 
incision  is  not  found  to  be  sufficient,  then  a  second  small 
incision  may  be  made,  extending  backwards  from  the  highest 
point  of  the  original  incision.  As  far  as  possible  it  is  advis- 
able to  make  the  incision  close  to  the  auricle  or  in  the  pos- 
terior auricular  groove,  so  that  the  resultant  scar  will  be 
hidden  by  the  pinna,  but  it  should  be  at  a  sufficient  distance  to 
admit  of  sutures,  if  such  are  to  be  applied.  Usually  from  one- 
fourth  to  one-half  inch  will  allow  readily  of  this,  and  it  should 
also  be  placed  at  such  a  distance  from  the  auricle  that  the 
field  of  operation  will  be  well  exposed,  yet  the  cicatrix  will 
be  hidden  as  much  as  possible,  and  the  auricle  to  retain  its 
normal  position.  Under  no  circumstances,  however,  should 
the  operative  field  be  lessened  for  any  of  these  reasons,  an 
incision  which  begins  immediately  below  the  temporal  line, 
about  one-half  inch  behind  the  insertion  of  the  auricle,  and 
being  placed  at  first  vertical,  then  slightly  curved  forward, 
and  then  extended  downward  to  near  the  tip  of  the  mastoid, 
will  usually  be  most  satisfactory.  Some  otologists  prefer 
to  reverse  this  procedure  and  begin  the  incision  over  the 


EXPLANATORY    NOTE    TO    PLATE    XXVI. 


This  plate  shows  the  primary  retro-auricular  incision  in  the  performance  of  the 
mastoid  operation.  This  incision  should  be  carried  through  the  periosteum  to  the 
mastoid  cortex. 


246 


PLATE  XXVI 


The  Simple  Mastoid  Operation.  247 

middle  of  the  mastoid  insertion  of  the  sterno-mastoid  muscle, 
about  a  fourth  or  half  an  inch  below  the  tip  of  the  process, 
and  from  this  point  it  is  carried  upwards  and  forwards,  close 
to  the  line  of  the  insertion  of  the  auricle,  where  it  follows 
this  line  to  a  point  directly  above  the  external  orifice  of  the 
auditory  canal.  Should  the  skin  over  the  mastoid  be  in- 
flamed or  infiltrated  to  any  extent,  the  incision  may  have  to 
be  made  still  larger,  and  it  may  be  even  necessary  to  make 
another  at  right  angles  to  it  to  sufficiently  expose  the  parts. 
In  practically  all  cases,  with  the  exception  of  a  very  small 
number  where  at  the  upper  end  the  incision  may  be  made 
only  through  the  skin,  it  is  essential  that  it  be  made  down 
to  the  bone,  the  first  incision  severing  any  muscular  tissue 
that  may  be  present  in  its  upper  part  with  the  fascia  and  the 
periosteum,  so  that  the  soft  parts  are  divided  throughout 
their  whole  extent. 

The  periosteum  is  then  pushed  forwards  and  backwards 
with  the  periosteal  elevator,  so  that  the  planum  mastoideum 
is  freely  exposed  and  the  bleeding  controlled.  Should  the 
incision  in  its  lower  part  have  been  well  forward,  the  pos- 
terior auricular  artery  will  be  severed  and  this  vessel,  with 
any  others  that  may  be  bleeding  freely,  should  be  clamped. 
As  a  rule,  after  the  periosteal  flaps  have  been  pushed  aside 
by  carefully  dissecting  this  membrane  up  from  the  osseous 
surface,  avoiding  tearing  it  as  much  as  possible,  the  oozing 
usually  ceases  from  the  pressure  exerted  upon  the  flaps  by 
the  retractors,  but  if  it  still  persists,  it  is  generally  controlled 
by  firm  pressure  with  gauze  sponges  wrung  out  in  hot 
water  and  retained  over  the  parts  for  a  few  moments,  one 
of  these  being  left  in  the  upper  part  of  the  incision  for  this 
purpose,  if  such  be  necessary.  In  those  cases  where  the  soft 
tissues  are  congested  and  where  the  oozing  is  excessive  and 
yet  of  such  an  extent  that  hsemostatics  are  of  no  use,  it  will 
be  necessary  to  delay  further  procedures  for  a  few  moments 


248  Suppuration  of  the  Middle  Ear. 

and  pack  the  entire  incision  with  small  sponges  as  described, 
while  in  those  cases  where  in  separating  the  posterior  perios- 
teal  flap  the  mastoid  emissary  vein  has  been  divided,  it  may 
be  necessary  to  pack  the  tissues  with  a  small  piece  of  gauze 
and  allow  it  to  remain  in  place  until  a  later  stage  of  the 
operation.  While  some  bleeding  from  this  vessel  is  not  at 
all  infrequent,  it  is  comparatively  rare  that  it  is  of  any 
moment,  but  in  these  cases  especially,  if  there  be  much  con- 
gestion about  the  head,  it  is  apt  to  produce  a  free  venous 
hemorrhage  and  for  a  time  cause  the  operator  considerable 
annoyance. 

Very  often  the  free  vascular  supply  of  the  anterior  flap 
causes  it  to  become  more  or  less  rapidly  cedematous,  but 
this  is  of  little  moment  and  requires  no  special  attention. 
The  flaps  should  be  retracted  so  that  the  cortex  is  well  ex- 
posed and  the  anterior  flap  especially  should  be  drawn  suffi- 
ciently forward,  so  that  the  supero-posterior  margins  of 
the  bony  canal  can  be  seen  in  order  that  the  landmarks  for 
guidance  to  the  antrum  can  be  accurately  located  (see  plate 
XXVII).  Various  retractors  may  be  used  for  this  purpose, 
but  in  cases  where  there  is  apt  to  be  much  pus  present,  it  is 
advisable  to  use  those  where  the  teeth  are  not  too  sharp,  as 
they  are  apt  to  lacerate  the  tissues  of  the  flap  and  materially 
increase  the  likelihood  of  causing  some  annoyance  from  sub- 
sequent local  infection. 

The  exposed  surface  of  the  cortex  is  then  carefully  ex- 
amined. In  the  great  majority  of  these  cases  it  will  appear 
to  be  perfectly  normal,  or  there  may  be  a  fistula  present, 
or  in  a  few  cases  a  portion  of  the  surface  will  appear  dark 
in  color,  or  mottled  here  and  there  with  small  bleeding 
points,  the  former  condition  indicating  a  beginning  necrosis, 
while  the  latter  suggesting  a  marked  congestion  or  engorge- 
ment of  the  venous  system  of  the  mastoid  interior.  Should 
bare  bone,  a  fistula  or  any  other  lesion  of  the  cortex  be 


EXPLANATORY    NOTE    TO    PLATE    XXVII. 


This  plate  shows  the  primary  incision  carried  through  the  skin  and  periosteum, 
with  the  soft  parts  retracted,  exposing  the  underlying  bone  and  the  field  of  operation. 
A  portion  of  the  external  cartilaginous  auditory  canal  is  also  exposed. 

i,  Retracted  skin;  2,  retracted  periosteum;  3,  linea  temporalis ;  4,  external  audi- 
tory canal ;  5,  supra-meatal  spine ;  6,  point  of  election  in  entering  the  antrum  (shaded 
portion). 

250 


PLATE  XXVII 


The  Simple  Mastoid  Operation.  251 

present,  it  is  always  advisable  to  ignore  it  for  a  time,  unless 
it  be  directly  over  the  site  of  the  antrum,  and  after  locating 
the  situation  where  it  is  desired  to  chisel  away  the  cortex  by 
careful  search  for  the  landmarks  previously  described,  the 
antrum  is  entered  as  the  objective  point,  when  attention  then 
can  safely  be  paid  to  the  lesions  of  the  cortex.  The  land- 
marks used  as  guides  to  determine  the  location  at  which 
the  opening  in  the  cortex  may  be  made  in  order  to  reach 
the  antrum  by  the  shortest  and  safest  route  have  already 
been  described  in  the  previous  chapter,  but  it  must  be  borne 
in  mind  that  after  the  cortex  has  been  exposed  in  order  to 
uncover  the  site  of  election,  it  is  necessary  that  the  pinna 
should  be  drawn  well  forward,  so  that  the  osseous  entrance 
to  the  meatus  can  be  seen,  as  the  auricle  in  its  natural  posi- 
tion covers  these  parts  and  is  placed  somewhat  over  the 
anterior  part  of  the  mastoid  process.  Bearing  in  mind  the 
location  of  the  antrum,  that  is  just  below  the  superior  and 
behind  the  posterior  margin  of  the  osseous  canal,  the  open- 
ing in  the  cortex  previous  to  the  opening  of  the  antrum 
should  not  be  extended  above  the  superior  wall  of  the  canal 
in  order  to  avoid  entering  the  middle  cranial  fossa,  and  at 
the  same  time  one  should  avoid  extending  the  opening  pos- 
teriorly, for  fear  of  encountering  the  lateral  sinus.  As  the 
postero-superior  wall  of  the  meatus  is  the  most  important 
landmark  for  this  purpose,  the  cortex  should  never  be  touched 
until  this  part  can  be  seen,  and  when  it  is  thus  located,  the 
antrum  can  always  be  reached  by  chiseling  inward  and  for- 
wards, parallel  to  this  portion  of  the  meatus,  and  as  the 
excavation  is  continued  in  this  direction,  one  should  use  the 
probe  at  frequent  intervals  to  determine  the  nearness  of  the 
antrum,  or  the  possible  exposure  of  the  meninges  or  lateral 
sinus.  Various  mechanical  devices  have  been  employed  for 
the  purpose  of  locating  the  antrum,  the  mastoid  hook  guide 
of  Buck  being  quite  serviceable  for  this  purpose.  As  em- 


252  Suppuration  of  the  Middle  Ear. 

ployed  by  its  author,  the  curved  end  is  introduced  from  above 
into  the  orifice  of  the  external  auditory  canal  and  held  by 
an  assistant  between  the  bone  and  the  overlying  soft  parts 
until  the  antrum  has  been  reached,  when  it  should  be  re- 
moved. When  it  is  hooked  into  the  canal,  the  hook  indi- 
cates the  position  of  the  posterior  upper  curve  of  the  orifice 
of  the  auditory  meatus,  and  the  position  of  the  antrum  is  a 
scant  quarter  of  an  inch  behind  and  a  little  above  that  of  the 
steel  knob.  Buck  further  states  that  the  operator  may  then 
satisfy  himself  that  he  has  reached  the  antrum  by  his  knowl- 
edge of  the  anatomy  of  this  region  telling  him  whether  the 
cavity  which  has  been  reached  fulfils  in  a  general  way  the 
anatomical  requirements  or  not.  If  its  distance  from  the 
surface  of  the  bone  by  actual  measurements  is  less  than  one 
half  inch,  it  would  simply  indicate  an  outlying  cell.  By 
introducing  a  probe  bent  at  nearly  a  right  angle  with  its 
shaft,  in  case  of  the  antrum  being  opened  it  will  slip  forward 
into  the  posterior  end  of  the  tympanum,  while  if  it  be  but 
an  outlying  pneumatic  cell,  the  probe  would  encounter  only 
a  rigid  wall.  This  may  also  be  ascertained,  he  states,  by 
forcing  fluid  or  air  under  moderate  pressure  in  the  tympanic 
cavity  by  way  of  the  external  canal,  and  it  will  then  come 
out  through  the  antrum,  but  any  pressure  in  the  reverse  direc- 
tion should  not  be  used.  If  a  depth  of  three-quarters  of 
an  inch  has  been  reached  without  finding  the  antrum,  one 
should  not  go  to  any  further  depth,  as  the  chances  are  the 
opening  is  either  too  low  down,  too  high,  or  too  far  back- 
wards, and  under  such  circumstances,  if  the  operator  is  in 
the  right  direction  and  he  is  sure  the  antrum  is  not  present, 
then  he  may  work  cautiously  forward  until  the  tympanum 
is  reached. 

The  situation  of  the  opening  in  the  cortex  of  the  mastoid 
should,  as  far  as  possible,  be  placed  just  behind  the  external 
meatus  and  immediately  below  its  superior  border ;  this  cor- 


The  Simple  Mastoid  Operation.  253 

responds  to  the  anterior  superior  quadrant  of  the  mastoid 
and  is  the  position  from  which  the  antrum  will  be  reached 
in  the  shortest  time.  It  should  lie  behind  the  linea  tem- 
poralis  at  the  height  of  the  superior  wall  of  the  external 
auditory  canal,  and  from  5  to  7  millimeters  behind  the  supra- 
meatal  spine.  By  following  this  plan  and  thus  opening  the 
antrum  as  the  initial  point,  one  is  able  to  obtain  definite 
information  as  to  the  condition  of  the  mastoid  interior,  and 
little  difficulty  will  be  found  in  working  intelligently  and 
safely  in  the  other  portions  of  the  osseous  tissue,  where  it 
may  be  necessary  to  remove  diseased  bone,  while,  if  one 
attempts  to  find  the  antrum  by  first  entering  any  sinus  which 
may  appear  on  the  cortex,  one  is  more  apt  to  go  astray. 
In  those  cases  where  it  is  desired  to  perform  this  operation, 
when  the  mastoid  is  eburnated,  the  opening  in  the  cortex 
should  always  be  in  a  direction  forward  and  upward  towards 
the  aditus,  very  much  like  Stacke's  operation,  in  order  to 
avoid  the  lateral  sinus  which  is  very  apt  to  be  placed  decidedly 
forwards  in  this  type  of  temporal  bone.  It  must  also  be 
remembered  in  all  cases,  whatever  the  type  of  bone  found, 
that  the  highest  point  of  the  opening  in  the  cortex  should  not 
be  placed  higher  than  the  upper  wall  of  the  osseous  canal, 
and  while  it  may  not  always  be  possible  to  exactly  define 
this  limit,  one  may  say  as  a  general  rule  that  it  corresponds 
to  the  depression  that  lies  below  the  spina;  this  depression, 
as  previously  mentioned,  being  directly  over  the  antrum 
and  in  a  few  cases  may  resemble  a  well-defined  pit.  When 
the  spina  suprameatus  is  not  present  and  cannot  be  utilized 
as  a  landmark,  one  must  guide  the  position  of  the  opening 
in  the  cortex  by  that  part  of  the  planum  mastoideum  which 
enters  into  the  posterior  wall  of  the  auditory  canal.  This 
landmark  is  used  as  the  anterior  limit  of  the  opening,  and 
its  superior  boundary  is  measured  by  the  upper  wall  of  the 
osseous  external  canal;  to  locate  these  osseous  boundaries  it 


254  Suppuration  of  the  Middle  Ear. 

is  necessary  that  the  auricle  be  pushed  far  forward  with  the 
periosteal  elevator,  so  that  the  postero-superior  circumfer- 
ence of  the  canal  can  be  both  seen  and  felt. 

In  order  to  remove  the  cortex  over  the  area  selected,  the 
chisel  and  mallet  may  be  employed  or  a  small  aperture  may 
be  drilled  in  the  bone  with  a  gouge  or  drill,  the  opening  being 
enlarged  and  the  mastoid  cells  between  the  cortex  and  the 
antrum  being  broken  down  with  the  chisel,  curette  and 
rongeur  forceps.  When  the  hand  gouge  is  employed  for 
this  purpose,  it  takes  a  longer  time  to  remove  the  bone  than 
when  the  mallet  and  chisel  are  used,  and  it  is  attended  with 
a  greater  degree  of  safety,  as  it  can  be  easily  controlled,  even 
when  the  hardest  bone  is  being  cut  through,  although,  in 
careful  hands,  it  offers  no  marked  advantages  over  the  em- 
ployment of  the  other  instruments  for  this  purpose.  Blake, 
in  order  to  make  the  aperture  in  the  cortex,  uses  a  long  broad- 
bladed  drill,  cutting  at  an  obtuse  angle,  and  which  is  rotated 
with  one  hand  while  it  is  held  firmly  in  place  with  the  other ; 
the  small  opening  thus  made  in  the  bone  being  enlarged  to 
the  size  desired  with  the  chisel.  Irrespective  of  the  nature 
of  the  instrument  employed  in  opening  the  cortex,  as  soon 
as  it  is  made  of  sufficient  size,  the  opening  is  enlarged  with 
the  rongeur  forceps,  and  as  in  the  majority  of  cases  it  is 
impossible  to  introduce  these  forceps  until  the  edges  have 
been  undermined  to  some  extent,  it  is  necessary  to  use  the 
various  forms  of  sharp  spoons  or  curettes,  especially  Volk- 
mann's,  which  are  admirably  adapted  for  this  purpose,  to 
remove  the  framework  of  the  pneumatic  or  diploic  tissue, 
in  order  to  excavate  the  softened  bone.  In  a  general  way 
both  the  drill  and  the  trephine  are  not  as  safe  as  the 
chisel,  as  when  the  latter  is  intelligently  employed  in  re- 
moving the  firm  cortex,  it  is  almost  impossible  to  do  any 
harm.  Both  large  and  small  straight  chisels  are  em- 
ployed for  this  purpose,  and  while  they  are  obtained  under 


EXPLANATORY    NOTE    TO    PLATE    XXVIII. 


This  plate  shows  the  external  cortex  of  the  mastoid  removed  and  the  mastoid 
antrum  opened. 

i,  Mastoid  antrum;  2,  probe  introduced  into  the  mastoid  antrum;  3,  the  remains 
of  the  posterior  osseous  wall  of  the  external  auditory  canal ;  4,  the  mastoid  cells 
removed  down  to  the  inner  table  of  the  skull. 

256 


PLATE  XXVIII 


The  Simple  Mastoid  Operation.  257 

various  names,  those  of  Schwartze  are  especially  valuable, 
as  they  are  both  strong  and  narrow,  the  latter  feature  ren- 
dering them  more  useful  than  a  broad  chisel  for  the  ma- 
jority of  cases.  As  near  as  possible,  the  chisel  should  be 
held  tangential  to  the  skull  and  but  small  chips  of  bone  should 
be  cut  away  with  each  blow  of  the  mallet,  a  lead-filled  or 
compressed  rawhide  mallet  being  best  for  this  purpose.  In 
cutting  away  the  hard  bony  layer  the  chisel  may  be  held 
with  its  bevel  edge  towards  the  inside  of  the  opening,  or  it 
may  be  held  in  a  reverse  position,  as  may  seem  best,  the  posi- 
tion of  the  instrument  in  this  respect  being  dependent  upon 
the  fancy  of  the  operator.  For  the  first  cutting  away  of 
the  opening  into  the  bone,  the  chisel  should  be  rather  large, 
but  as  the  cavity  becomes  smaller  inward  a  narrower  one 
should  be  employed  and  held  more  at  an  angle  to  the  bone 
than  the  large  chisel.  When  the  mastoid  is  large  and 
rounded  and  the  chisel  is  applied  nearly  parallel  to  the  sur- 
face of  the  bone,  fairly  large,  thin,  broad  chips  may  be  cut 
away  from  the  superficial  layers  of  the  cortex,  the  cutting 
edge  being  directed  forward  and  downward,  so  that  when 
the  antrum  has  been  entered  the  cavity  forms  a  funnel-shaped 
entrance,  with  its  large  base  represented  by  the  opening  in 
the  cortex  and  its  apex  lying  in  the  post-meatal  triangle  which 
directly  points  inwards  to  the  antrum  (see  plate  XXVIII). 
When  the  mastoid  process  is  very  hard  and  compact  in  struc- 
ture and  the  curette  or  gouge  are  unable  to  make  but  little 
impression  upon  it,  the  chisel  is  necessary  to  remove  the  layer 
of  bone  external  to  the  antrum,  but  as  in  these  cases  the  latter 
cavity  is  apt  to  be  small,  one  should  proceed  very  cautiously, 
and  constantly  bear  in  mind  the  exact  direction  in  which  it 
is  desired  the  canal  should  be  made,  as  in  using  the  chisel  for 
this  purpose,  if  one  does  not  pay  strict  attention  to  this  essen- 
tial point,  the  chisel  may  be  directed  too  far  upward,  and  the 
cranial  fossa  may  be  entered  above  the  roof  of  the  antrum, 

18 


258  Suppuration  of  the  Middle  Ear. 

or  again,  if  it  be  directed  too  far  inferiorly,  the  extremely 
compact  mass  of  osseous  tissue  containing  the  facial  nerve 
near  the  aditus  will  be  encountered,  but  this  latter  accident 
can  only  occur  in  very  exceptional  cases. 

The  size  of  the  opening  in  the  cortex  should,  as  a  general 
rule,  be  as  large  as  possible,  so  that  any  increase  in  the  intra- 
tympanic  pressure  may  be  relieved,  and  in  order  that  soft- 
ened bone  and  granulation  tissue  can  be  thoroughly  removed. 
Where  the  tissue  changes  are  but  limited  in  extent,  and 
the  main  object  of  the  operation  is  to  obtain  free  drainage 
through  the  tympanum  and  antrum,  a  space  of  about  one 
centimeter  square  immediately  behind  the  upper  part  of  the 
meatus  and  on  a  level  with  the  supramastoid  ridge,  will 
usually  suffice  at  least  for  the  initial  opening,  as  it  can  then 
be  enlarged  to  suit  the  exigencies  of  the  case,  if  the  condi- 
tion of  the  mastoid  interior  demands  it.  When  the  pneu- 
matic cells  have  been  exposed  and  granulation  tissue  or 
pus  is  found,  the  opening  in  the  bone  should  be  enlarged  to 
a  size  sufficient  to  remove  all  the  diseased  tissue,  so  that  if 
it  be  made  of  sufficient  size,  one  is  enabled  with  good  illu- 
mination to  see  exactly  what  is  being  done,  and  diseased 
tissue  in  the  interior  may  be  safely  removed,  even  in  the 
region  of  the  antrum  and  aditus,  without  any  danger  of 
damaging  the  facial  or  horizontal  semicircular  canals. 
Schwartze  states  that  the  size  of  the  opening  in  the  cortex 
should  be  about  twelve  millimeters,  while  Bezold  thinks  seven 
millimeters  is  sufficient,  but  the  larger  the  opening,  compat- 
ible with  safety,  the  better  will  be  the  ultimate  results  of  the 
operation,  as  with  a  large  opening  one  can  see  better,  the 
antrum  is  more  readily  found,  and  what  is  also  important, 
if  the  opening  in  the  bone  be  made  too  small,  the  wound  is 
very  apt  to  close  before  the  cavity  heals  from  the  bottom 
and  pus  retention  is  fairly  sure  to  take  place,  necessitating 
its  reopening. 


The  Simple  Mastoid  Operation.  259 

While  the  pathological  changes  found  in  the  mastoid 
interior  vary  in  almost  every  case,  at  least  in  detail,  it 
seems  to  be  a  fixed  law,  as  shown  by  Politzer,  that  with 
chronic  suppurative  processes  near  the  antrum  a  subacute 
condensing  osteitis  takes  place  which  involves  all  the  pneu- 
matic spaces  which  escape  injury  during  the  original  acute 
attack.  This  is  characterized  by  the  formation  of  new  bone 
tissue,  until  solid  ivory-like  bone  replaces  the  air  cells  and 
sclerosis  or  hyperostosis  of  the  cortex  is  a  regular  charac- 
teristic of  chronic  suppurative  otitis  media.  As  has  also 
been  shown  as  having  an  important  bearing  on  the  symp- 
toms such  a  bony  wall  on  the  outer  side  offers  an  impassable 
barrier  to  the  escape  of  pus,  and  so  the  characteristic  symp- 
toms seen  in  acute  mastoiditis  are  absent  of  necessity.  In 
some  cases  the  degree  of  the  chronic  proliferative  osteitis  will 
be  found  so  marked  that  in  addition  to  the  usual  oblitera- 
tion of  the  cells,  the  small  venous  channels  are  also  entirely 
effaced  and  the  entire  mastoid  process  is  converted  into 
dense,  eburnated  bone,  so  that  the  antrum  is  considerably 
reduced  in  size  and  its  location  becomes  a  matter  of  consid- 
erable difficulty.  This  only  occurs,  however,  when  the 
chronic  suppuration  has  existed  over  many  years,  and  when 
this  condition  occurs  in  individuals  at  or  past  middle  life, 
and  even  a  slight  discharge  is  present  from  the  middle  ear, 
they  should  be  strongly  urged  to  have  an  operation  per- 
formed on  account  of  the  extreme  thickness  of  the  cortex 
markedly  increasing  the  tendency  towards  the  deeper  exten- 
sion of  the  purulent  process,  be  it  soever  limited  in  extent. 
When  this  condition  is  surmised,  however,  in  advance  of 
operation,  it  is  futile  to  expect  favorable  results  from  the 
mere  opening  of  the  mastoid,  and  in  order  to  cure  the  sup- 
puration the  posterior  wall  of  the  auditory  canal  must  be 
removed  to  reach  the  antrum,  so  that  a  Stacke  or  Zaufal 
operation  is  usually  indicated;  the  former  if  the  condition 


260  Suppuration  of  the  Middle  Ear. 

be  recognized  previous  to  opening  the  cortex,  and  if  not,  the 
simple  operation  should  be  so  modified  and  enlarged  as  to 
suit  the  particular  case. 

In  a  second  large  group  of  cases,  the  conditions  present 
in  the  mastoid  interior,  after  the  cortex  has  in  part  been 
removed,  are  directly  opposite  to  those  just  described,  and 
instead  of  the  development  of  new  tissue,  we  find  a  breaking 
down  of  the  walls  of  the  pneumatic  spaces,  with  limited 
caries  and  necrosis.  Briefly  noted,  these  changes  may  be 
found  side  by  side  in  one  case,  or  one  or  more  may  pre- 
dominate and  necessitate  the  performance  of  a  radical  oper- 
ation instead  of  the  more  simple  one.  As  shown  by  Politzer, 
there  may  be  hypertrophy  of  the  mucous  membrane  of  the 
antrum  and  mastoid  cells,  due  to  proliferation  of  round  cells, 
so  that  the  mastoid  spaces  become  filled  up  and  obliterated 
by  the  proliferating  mucosa.  This  tissue  may  persist,  how- 
ever, or  it  may  become  transformed  into  bone,  causing  par- 
tial or  complete  eburnation  of  the  mastoid,  or  again,  we  may 
find  a  granular  osteitis  and  carious  softening  of  the  walls 
of  the  antrum,  which  becomes  abnormally  widened,  rarely 
narrowed,  or  complete  destruction  of  the  antrum  with  ex- 
tensive sclerosis  of  the  mastoid  process.  In  other  cases  there 
may  be  a  circumscribed  or  diffuse  caries  or  necrosis  of  the 
mastoid,  with  or  without  the  formation  of  a  sequestrum. 
Cholesteatoma  of  the  antrum  or  mastoid  cells  may  also  be 
present  with  the  presence  of  pus  and  thickened  caseous 
masses  similar  to  tubercular  material,  while,  as  a  rule,  in  all 
cases  of  long  standing,  hyperostoses  and  osteo-sclerosis  of 
the  bone  takes  place,  surrounding  the  seat  of  the  disease. 
At  one  place  in  the  bone  the  various  infecting  organisms 
present  may  produce  but  sufficient  irritation  to  cause  the 
development  of  a  group  of  granulation  tissue,  while  in  an 
adjacent  area  the  epithelial  cells  will  appear  to  have  borne 
the  brunt  of  the  inflammatory  changes  and  excessive  prolif- 


The  Simple  Mastoid  Operation.  261 

eration  will  have  taken  place,  forming  irregular  groups  of 
cells  or  a  well-defined  laminated  cholesteatomatous  mass, 
with  thick  curdy  pus  and  considerable  destruction  of  the 
osseous  wall  surrounding  it,  so  that  when  this  condition  is 
revealed,  it  is  necessary  to  eviscerate  the  entire  affected  mas- 
toid  and  tympanic  contents  and  preferably  maintain  a  perma- 
nent retro-auricular  opening,  as  will  later  be  described.  In 
the  larger  number  of  cases  operated  upon  for  the  cure  of 
the  chronic  tympanic  suppuration,  granulation  tissue,  more 
or  less  epithelial  debris  and  carious  areas  will  be  found  after 
the  antrum  has  been  opened,  while  the  vertical  part  of  the 
mastoid  will  be  found  less  frequently  involved,  irrespective 
of  the  nature  of  the  mastoid  structure.  Unless  the  patho- 
logical changes  of  the  osseous  structure  itself  are  well 
marked,  it  is  often  difficult  to  determine  by  inspection,  and 
even  from  the  degree  of  firmness  of  the  bone,  whether  it  is 
sufficiently  healthy  to  be  allowed  to  remain  or  should  be 
removed.  If  it  is  very  vascular,  of  a  dark  red  color  and 
when  cut  bleeds  persistently,  or  there  is  the  reverse  of  this, 
that  is,  a  complete  stasis  of  the  vascular  channels,  it  is  prob- 
ably involved  to  such  an  extent  that  it  will  be  impossible  for 
it  to  again  return  to  the  normal  condition,  and  it  should  be 
removed  until  absolutely  healthy  bone  is  reached.  If  the 
field  of  operation  be  made  sufficiently  large,  it  is  usually  pos- 
sible to  recognize  and  remove  the  grosser  evidences  of  the 
diseased  osseous  tissue,  these  areas,  if  not  actually  broken 
down,  often  being  clearly  distinguished  by  masses  of  granu- 
lations in  the  cell  spaces,  and  when  this  occurs,  one  will 
always  be  safe  in  removing  such  areas  in  toto,  with  the  bone 
in  their  immediate  vicinity. 

In  many  of  these  cases  it  is  of  course  impossible  to  tell 
until  the  interior  of  the  mastoid  has  been  reached  whether  a 
condensing  osteitis  or  an  empyema  with  more  or  less  exten- 
sive necrosis  is  present,  and  very  often  the  subjective  or 


262  Suppuration  of  the  Middle  Ear. 

objective  symptoms  do  not  agree  in  any  way  with  the  patho- 
logical changes  which  are  found  on  operation,  as  one  may 
have  more  or  less  serious  symptoms  and  yet  there  will  be 
but  a  small  amount  of  granulation  tissue  present.  While  in 
other  cases  all  symptoms  except  a  slight  discharge  from  the 
canal  will 'be  absent  and  when  the  cortex  of  the  mastoid 
has  been  removed,  extensive  and  serious  disorganization  of 
the  temporal  bone  may  be  disclosed,  the  uncertainty  of  the 
nature  of  the  pathological  changes  being  recognized  previous 
to  opening  the  bone,  and  is  well  expressed  by  Schwartze  when 
he  states  that  often  the  diagnosis  of  empyema  of  the  mastoid 
is  made  only  after  operation.  The  bony  structure,  whether 
consisting  of  large  cells  or  diploic  tissue  beneath  the  cortex, 
should  be  removed  with  the  curette  or  sharp  spoon,  and  this 
must  be  continued  until  the  antrum  is  reached.  The  extent 
of  the  removal  of  the  cells  depends  entirely  upon  the  amount 
of  the  disease  present,  and  that  which  may  be  regarded  as 
the  simple  opening  of  the  antrum  in  some  cases  will  ulti- 
mately, as  the  result  of  finding  extensive  disease  present, 
be  finally  terminated  in  a  complete  evisceration  of  the  parts. 
Should  it  be  found  that  the  tip  of  the  mastoid  is  filled  with 
pus,  the  opening  in  the  cortex  should  be  sufficiently  enlarged 
to  enable  one  to  remove  this  cellular  group,  and  if  the  dis- 
ease appears  to  be  extensive  in  this  locality,  one  should  care- 
fully dissect  up  the  bony  insertion  of  the  sterno-mastoid  mus- 
cle with  curved  scissors  and  examine  the  osseous  tissue  re- 
maining for  a  carious  process  of  the  medial  plate  leading  into 
the  digastric  fossa. 

As  we  may  now  consider  that  the  antrum  has  been 
opened,  one  should  then  proceed  to  lay  bare  all  accessory 
cells  that  may  be  diseased,  so  that  the  cavity  remains  per- 
fectly clean  and  no  pockets  are  left  that  may  continue  the 
aural  suppuration.  Even  should  a  sinsrle  isolated  cell  be  left 
containing  pus,  the  symptoms,  although  relieved  for  a  time, 


The  Simple  Mastoid  Operation.  263 

will  generally  persist,  and  it  will  later  become  necessary  to 
perform  a  secondary  operation.  In  many  of  these  cases,  after 
exposing  the  antrum  and  excavating  downwards  with  the 
curette  towards  the  tip,  one  is  very  apt  to  find  one  or  two  large 
pneumatic  cells  here  and  after  these  have  been  destroyed,  it  is 
well  to  explore  in  a  backward  direction  towards  the  temporo- 
occipital  junction  and  then  again  using  the  antrum  as  an  objec- 
tive point,  the  bone  may  be  explored  upwards  and  backwards 
towards  the  inner  osseous  plate.  Should  the  inner  table  be 
involved  in  the  carious  process,  it  is  essential  that  it  be  re- 
moved, and  although  both  dura  and  lateral  sinus  will  thus  be 
exposed,  yet  in  such  instances  if  proper  antiseptic  precau- 
tions have  been  employed,  one  can  be  fairly  confident  that 
this  will  not  seriously  complicate  the  operation.  Irrespective 
of  the  structure  of  the  mastoid,  that  is,  whether  it  is  can- 
cellated or  not,  and  this  latter  variety  may  sometimes  extend 
far  backwards  and  even  far  inwards,  it  should  be  remem- 
bered that  it  is  absolutely  essential  to  widely  open  all  pus 
cavities  or  spaces  in  which  pus  may  lodge.  The  antrum  and 
the  passage  between  it  and  the  tympanic  cavity  should  also 
be  curetted  with  a  small  sharp  spoon,  as  in  many  cases  where 
this  method  of  opening  the  mastoid  is  employed,  the  major 
part  of  the  disease  will  be  found  located  here,  and  the  ces- 
sation of  the  tympanic  purulency  will  to  a  great  extent  de- 
pend upon  the  removal  of  the  granulation  tissue  and  pos- 
sibly the  carious  bone  areas  from  the  region  of  the  aditus. 
While,  as  before  mentioned,  it  may  be  sometimes  quite  diffi- 
cult to  differentiate  normal  from  diseased  bone,  yet  as  a  rule 
the  latter  is  easily  broken  down  with  the  sharp  spoon,  and 
if  one  finds  that  in  the  particular  case  this  is  the  condition 
met  with,  it  should  always  be  scraped  away  until  healthy 
osseous  tissue  is  reached,  and  this  is  usually  recognized  by 
a  certain  peculiar  resistance  which  it  offers  to  the  cutting 
instrument.  The  extent  of  the  removal  of  the  mastoid  con- 


264  Suppuration  of  the  Middle  Ear. 

tents,  will  as  a  fact,  depend  upon  meeting  the  healthy  bone 
surrounding  the  involved  parts,  and  as  one  of  the  aims  of 
this  procedure  is  to  destroy  as  little  of  the  parts  as  possible, 
although  this  is  but  a  secondary  and  minor  consideration,  it 
is  not  advisable  to  extend  the  operation  beyond  the  affected 
area  unless  there  are  well-defined  reasons  for  so  doing,  and 
as  has  been  stated  by  several  authors,  this  should  be  the 
guiding  rule  as  to  how  extensive  an  operation  should  be 
performed  in  such  cases,  McBride  in  this  connection  not 
considering  it  always  necessary  to  clear  out  the  mastoid  in 
such  cases  of  chronic  otorrhoea.  After  the  diseased  tissue 
has  been  removed  as  indicated,  the  walls  of  the  cavity  which 
has  been  made  irrespective  of  its  size,  should  in  all  points  be 
composed  of  firm,  healthy  bone,  and  after  this  has  been  ascer- 
tained, the  edges  of  the  external  opening  of  the  cavity  should 
be  smoothed  down  with  the  rongeur  forceps  and  any  over- 
hanging border  which  still  remains  must  also  be  removed  in 
the  same  way,  so  that  no  irregular  edges  will  be  left  to  cause 
trouble  with  the  later  dressing  of  the  wounds. 

Previous  to  the  curetting  of  the  mastoid  cells,  one  should 
always  be  sure  that  the  antrum  has  been  opened.  Should 
the  mastoid  not  contain  marked  pneumatic  tissue,  it  is  not 
advisable  to  penetrate  to  a  greater  depth  than  three-quarters 
of  an  inch  for  fear  of  wounding  the  facial  canal  or  the 
labyrinth,  for  as  a  rule,  the  antrum  is  rarely  less  than  one- 
half  an  inch  from  the  cortex,  and  it  may  be  verified  by  pass- 
ing a  moderately  curved  probe  through  it  in  a  downward, 
forward  and  inward  direction,  so  that  if  the  space  be  the  an- 
trum, the  probe  will  be  felt  in  the  tympanic  cavity  as  it  passes 
through  the  aditus,  instead  of  meeting  the  obstruction  of  os- 
seous walls  should  the  cavity  be  but  a  large  pneumatic  space 
lying  between  the  antrum  and  the  exterior  of  the  mastoid  (see 
plate  XXVIII).  It  is  impossible  in  searching  for  the  antrum 
to  know  the  depth  of  the  canal  which  is  being  excavated  and 


EXPLANATORY    NOTE    TO    PLATE    XXIX. 


This  plate  shows  the  completed  simple  mastoid  operation  (Schwartze)  on  a  bone 
specimen. 

i,  zygomatic  process;  2,  external  auditory  canal;  3,  posterior  osseous  canal  wall; 
4,  stylo-mastoid  process ;  5,  an  opened  terminal  (tip)  cell  of  the  mastoid  process ;  6, 
bony  prominence  over  the  sigmoid  sinus ;  7,  digastric  fossa ;  8,  mastoid  antrum. 

266 


PLATE  XXIX 


The  Simple  Mastoid  Operation.  267 

which  various  authorities  quote  different  distances  from  the 
cortex  to  the  external  wall  of  the  antrum,  and  yet  the  differ- 
ent figures  can  be  fairly  well  harmonized  if  one  considers 
that  the  point  from  which  the  measurements  are  made  on 
the  cortex  varies  in  the  different  methods  recommended  for 
opening  the  mastoid.  This  is  shown  by  Politzer,  who  states 
that  Schwartze  gives  the  distance  from  the  posterior  edge 
of  the  opening  in  the  bone  to  the  antrum  as  about  twelve  to 
eighteen  millimeters,  while  Bezold,  measuring  from  the  an- 
terior edge  of  the  bony  opening,  makes  it  but  twelve  milli- 
meters. As  the  distance  of  the  spina  from  the  supero- 
posterior  periphery  of  the  membrana  tympani  averages  about 
fifteen  millimeters,  an  important  guide  is  thus  furnished  how 
far  we  may  advance  when  chiseling  away  the  osseous  tissue. 
The  distance  between  the  middle  of  the  external  opening  in 
the  bone  and  the  external  wall  of  the  antrum  varies  from  six 
to  fifteen  millimeters,  and  as  the  horizontal  semicircular 
canal  or  facial  nerve  is  reached  at  a  depth  of  from  twenty 
to  twenty-two  millimeters,  one  should  not  go  deeper  than 
eighteen  millimeters  if  the  antrum  is  not  found. 

In  children,  as  has  already  been  shown,  the  antrum  lies 
much  nearer  the  surface,  and  in  many  cases  of  chronic  sup- 
purative  otitis  in  this  class  of  patients,  the  simple  opening 
of  the  mastoid  will  be  all  that  is  indicated,  the  procedure 
being  carried  out  essentially  as  in  adults  as  regards  the  oper- 
ative technique,  but  in  very  young  children  with  due  regard 
to  the  varied  topography  of  the  temporal  bone.  Meniere, 
in  a  comprehensive  study  of  the  mastoid  changes  in  chil- 
dren as  influencing  the  operative  treatment  of  chronic  sup- 
purative  otitis  media,  found  that  the  condition  is  quite  fre- 
quent, being  present  in  three  hundred  and  fifty-six  of  one 
thousand  seven  hundred  and  forty-eight  cases.  He  also 
states  that  as  the  mastoid  is  formed  during  the  first  year  of 
life  by  the  slow  absorption  of  cancellous  bone,  the  often  slow, 


268  Suppuration  of  the  Middle  Ear. 

painless  and  insidious  course  of  affections  of  the  mastoid 
cells  may  be  readily  explained  and  the  extension  of  the  mas- 
toid caries  from  the  interior  to  the  exterior  without  pain  or 
symptoms  is  frequently  observed  in  predisposed  young  sub- 
jects where  the  aural  suppuration  has  not  been  properly 
treated.  Notwithstanding  the  benignity  of  this  consequent 
mastoiditis  in  many  young  children,  if  proper  local  antiseptic 
treatment  does  not  cure  the  affection,  one  should  first  remove 
the  carious  ossicles,  and  if  this  is  not  sufficient,  then  open 
the  mastoid  and  if  necessary  continue  with  the  exposure  of 
the  middle  ear,  such  radical  procedures  being  necessary 
because  experience  has  shown  that  the  mastoid  infection 
occurs  insidiously  and  slowly  and  often  does  not  give  any 
early  diagnostic  symptoms. 

The  dangers  of  curetting  are  reduced  to  a  minimum  if 
care  is  used  in  dangerous  areas,  and  if  the  amount  of  force 
used  be  not  in  excess  of  that  necessary  to  remove  the  diseased 
tissue.  In  the  antrum,  when  the  sharp  spoon  is  employed, 
care  of  course  must  be  observed  on  account  of  the  important 
structures,  and  in  curetting  well  into  the  aditus  one  should, 
as  in  the  operations  through  the  intact  meatus,  cut  away 
from  the  facial  canal  and  the  stapedial  region,  rather  than  in 
a  direction  towards  them,  while  in  all  parts  of  the  mastoid 
process  precautions  must  be  taken  against  undue  force,  ex- 
cept when  one  is  in  the  direct  line  of  the  antrum,  when  con- 
siderable force  may  be  employed  here  as  long  as  one  keeps 
in  a  direction  forward  and  below  the  upper  wall  of  the  ex- 
ternal canal.  The  danger  of  accidentally  opening  the  lateral 
sinus  is  not  at  all  a  theoretical  one  in  these  cases  of  chronic 
suppuration,  as  the  mastoid  structure  is  often  sclerosed  and 
exceedingly  hard  and  at  the  same  time  the  sinus  is  in  closer 
relation  to  the  auditory  canal  than  in  the  perfectly  normal 
mastoid.  As  the  curette  or  spoon  is  of  little  or  no  value 
under  these  circumstances,  the  chisel  must  be  employed  and 


The  Simple  Mastoid  Operation.  269 

every  step  of  the  operation  carefully  watched  for  the  sinus 
wall,  as  in  some  cases  it  is  perfectly  possible  that  this  vas- 
cular channel  may  be  placed  so  far  forwards  that  there  is 
little  space  for  the  particular  operative  field.  As  a  guiding 
rule  to  avoid  the  possibility  of  opening  the  sinus,  one  should 
at  first  excavate  the  bone  in  a  limited  area  inwards,  forwards 
and  slightly  downwards  and  keep  as  close  as  possible  to  the 
canal  wall,  enlarging  the  upper  part  of  the  excavation  as 
one  works  inwards.  Chincini  reports  four  cases  of  invol- 
untary opening  of  the  sinus  during  operation,  but  the  hemor- 
rhage was  controlled  by  plugging  with  gauze  and  all  the 
patients  recovered  without  any  complicating  condition. 
Should  the  antrum  be  entered  without  interfering  with  the 
sinus,  the  posterior  wall  of  the  funnel-shaped  cavity  should 
be  carefully  chiseled  away  if  necessitated  by  pathological 
changes  present,  as  this  is  the  portion  in  relation  to  the  sinus, 
but  in  the  vast  majority  of  cases  if  the  chisel  be  held  cor- 
rectly, that  is,  the  cutting  edge  in  a  direction  forming  an 
acute  angle  with  the  vessel,  there  will  be  practically  no  dan- 
ger, as  if  the  sharp  edge  of  the  chisel  should  press  against 
the  elastic  wall  of  the  vessel  the  instrument  will  usually  push 
it  aside  without  doing  any  damage  unless  its  walls  are  dis- 
eased, when  profuse  dark  venous  hemorrhage  immediately 
occurs.  Sometimes  in  removing  the  bone  in  the  region  of 
the  sinus  a  profuse  hemorrhage  may  take  place  that  for  an 
instant  simulates  very  closely  the  profuse  bleeding  from  an 
open  sinus,  but  by  firm  pressure  with  gauze  for  a  few  mo- 
ments this  will  cease  and  it  will  then  be  seen  that  it  comes 
from  the  mastoid  emissary  vein  which  has  been  severed  near 
the  point  where  it  empties  into  the  sinus.  Should  the  re- 
moval of  an  area  of  bone  expose  the  sinus  wall,  it  may  be 
readily  recognized  by  its  position,  that  is,  internal  or  pos- 
terior to  the  cavity  which  is  being  excavated,  and  also  by  its 
bluish-gray  coloring,  while  the  probe  will  show  that  it  can 


270  Suppuration  of  the  Middle  Ear. 

be  indented  by  light  pressure.  Should  the  sinus  be  acci- 
dentally perforated  when  the  cortex  has  been  extensively  re- 
moved and  the  bone  cavity  is  of  fairly  large  size,  the  hem- 
orrhage may  be  controlled  by  packing  over  the  bleeding  area 
with  iodoform  gauze  and  retaining  it  in  place  for  about 
twenty-four  hours,  while  the  operative  procedures  in  other 
portions  of  the  bone  cavity  may  usually  be  continued,  but 
when  the  opening  in  the  cortex  is  small,  it  may  be  necessary 
to  entirely  fill  it  with  the  gauze  to  control  the  bleeding,  and 
under  these  circumstances  it  will  be  impossible  to  continue 
the  operation  until  the  sinus  wall  has  healed. 

As  the  roof  of  the  antrum  forms  in  part  the  middle  cere- 
bral fossa,  its  position  externally  is  figured  by  the  linea  tem- 
poralis,  the  floor  of  the  fossa  practically  never  being  over  a 
centimeter  below  this  line,  so  in  the  vast  majority  of  cases 
one  can  avoid  wounding  the  dura  when  endeavoring  to  enter 
the  antrum  or  removing  the  necrosed  tissue  from  this  par- 
ticular region  by  keeping  about  a  centimeter  below  the  tem- 
poral line  when  this  can  be  used  as  a  landmark,  while  in  those 
exceptional  cases  where  it  can  not  be  plainly  made  out,  the 
upper  edge  of  this  portion  in  the  opening  in  the  bone  should 
be  from  two  to  three  millimeters  below  a  line  drawn  hori- 
zontally backwards  from  the  postero-superior  edge  of  the 
external  meatus.  If  minute  attention  be  paid  to  the  anti- 
septic features  of  this  operation,  such  accidental  exposure 
of  the  sinus  and  dura  will  not  be  of  very  serious  importance, 
as  the  small  area  of  bone  exposing  them  will  reform  within 
a  reasonable  time  if  it  be  anyway  healthy.  Sometimes  if 
the  dura  be  exposed,  it  may  be  subjected  to  a  certain  degree 
of  traumatism  by  small  sharp-pointed  splinters  of  bone 
during  the  removal  of  necrosed  osseous  tissue  in  its  vicinity, 
but  if  care  be  taken  to  use  the  curette  under  such  circum- 
stances, this  is  not  liable  to  happen,  and  if  of  necessity  the 
chisel  be  employed,  this  danger  to  the  meninges  may  be 


The  Simple  Mastoid  Operation.  271 

almost  always  avoided  by  chiseling  away  the  osseous  tissue 
in  a  direction  parallel  to  the  roof  of  the  antrum.  Before 
describing  the  finishing  steps  of  this  operation,  brief  atten- 
tion must  be  directed  to  the  danger  of  extensive  destruction 
of  bone  which  may  sometimes  follow  the  infection  of  opening 
lip  the  diploic  tissue,  while  these  cases  are  quite  unusual, 
yet  they  are  being  reported  more  and  more  in  the  literature 
and  resemble  closely  a  well-defined  osteomyelitic  process. 
While  this  extension  of  osseous  infection  may  be  dependent 
upon  numerous  factors,  some  recognizable  and  others  ob- 
scure, yet  much  may  be  done  towards  its  prevention  by 
rigid  attention  to  aseptic  precautions  previous,  during  and 
following  operation  until  the  aural  suppuration  has  entirely 
ceased,  and  if  every  portion  of  the  osseous  tissue  exposed  is 
surgically  cleansed  and  all  foci  for  further  retention  of 
pathogenic  organisms  removed,  the  dangers  of  an  extension 
of  the  carious  process  through  the  spaces  in  a  diploic 
mastoid  will  be  reduced  to  a  minimum  or  entirely  abolished. 
In  place  of  the  chisel,  spoon  or  gouge,  an  electric  burr 
may  be  employed  to  both  open  the  mastoid  cortex  and  exca- 
vate its  interior,  but  while  it  has  been  employed  to  a  consid- 
erable extent  abroad,  it  has  not  received  much  encourage- 
ment as  yet  in  this  country,  although  no  very  serious  objec- 
tions have  been  urged  against  it,  and  in  some  cases  it  is 
undoubtedly  very  efficient  to  remove  the  osseous  tissue  in  this 
particular  operation.  Its  virtues  for  this  purpose  having 
been  promulgated  by  Lombard,  who  states  that  by  its  use  one 
avoids  the  shock  of  the  blow  from  the  mallet  which  is  inevi- 
table when  the  chisel  is  employed,  the  operation  is  more 
rapid;  the  bone  cavity  can  be  made  smooth,  with  no  angles, 
asperities  or  scales,  and  it  is  more  exact,  as  it  does  not  slip 
as  easily  as  the  chisel  and  gouge,  while  if  it  should  slip,  the 
results  are  not  serious.  Further  than  this,  there  is  no  risk 
of  wounding  parts  that  should  be  protected,  as  the  facial 


272  Suppuration  of  the  Middle  Ear. 

nerve,  the  semicircular  canal,  the  meninges  and  sinus,  while 
if  any  one  of  these  should  be  reached,  the  spheroidal  form 
of  the  burr  pushes  the  tissue  ahead  without  cutting  or  wound- 
ing it.  If  the  apophysis  is  eburnated,  he  states  that  the  burr 
is  always  successful  if  properly  used  with  sufficient  force, 
and  it  is  especially  useful  in  separating  the  sinus  wall  from 
its  osseous  canal;  the  objection  that  has  been  raised  against 
it,  that  it  becomes  overheated  and  destroys  the  tissues,  being 
not  borne  out  in  actual  experience,  as  the  necessary  pauses 
during  the  operation  allow  it  to  become  cool. 

During  the  excavation  of  the  mastoid  interior,  more  or 
less  bleeding  from  the  diploic  bone  surrounding  the  pneu- 
matic spaces  and  from  the  curetting  of  granulation  tissue 
always  takes  place,  but  in  the  great  majority  of  cases  this 
is  speedily  controlled  by  pressure  with  gauze  sponges,  either 
dry  or  wet,  with  a  hot  antiseptic  solution.  In  a  few  in- 
stances, however,  this  bleeding  may  be  quite  severe  and 
prove  most  annoying,  when  it  is  necessary  to  temporarily 
stop  the  operation  from  time  to  time  and  pack  the  cavity 
made  in  the  osseous  tissue  with  gauze.  This  packing  or  the 
application  of  very  hot  sterile  water  will  in  nearly  all  such 
cases  control  the  hemorrhage,  but  in  a  small  class,  the  oozing 
from  the  bone  surfaces  will  continue  to  the  end  of  the  opera- 
tion almost  irrespective  of  what  is  done  to  control  it.  After 
all  the  diseased  tissue  has  been  removed  and  the  operation 
completed,  the  haemostats  are  removed,  and  as  a  rule  the  pres- 
sure and  torsion  of  the  larger  vessels  will  have  effectually 
sealed  them,  but  if  any  should  persist  in  bleeding,  they  should 
be  ligatured,  preferably  with  fine  gut.  The  bleeding  being 
entirely  controlled,  the  parts  may  then  be  irrigated  or  not 
as  may  seem  most  desirable  in  the  particular  case.  If  but 
little  pus  or  carious  bone  has  been  found,  the  dressings  may 
be  applied  after  the  parts  have  been  cleansed  with  gauze 
sponges,  but  in  the  majority  of  cases  this  will  not  be  suffi- 


The  Simple  Mastoid  Operation.  273 

cient  and  irrigations  are  required.  For  this  purpose  a  phys- 
iological salt  solution,  carbolic,  boracic  or  bichloride  of  mer- 
cury solutions  of  weak  strength  may  be  employed  by  syring- 
ing through  the  retro-auricular  wound  and  allowing  the  solu- 
tion to  flow  through  the  antrum  and  tympanum  out  from 
the  external  canal.  Should  bichloride  be  used,  either  in  a 
i  to  5000  or  stronger  solution,  care  should  be  taken  that  it 
does  not  flow  through  the  Eustachian  tube  into  the  pharynx, 
for  if  this  should  occur,  it  will  irritate  these  parts  to  such 
an  extent  that  the  patient  will  suffer  a  great  deal  of  distress 
for  a  day  or  more.  Probably  the  most  satisfactory  solution 
for  irrigation  is  the  saline  solution  mentioned,  or  warm  sterile 
water. 

After  the  field  of  operation  has  thus  been  thoroughly 
cleansed,  it  must  be  decided  as  to  whether  the  wound  should 
be  entirely  closed  or  be  packed  so  that  it  will  heal  by  granu- 
lation. If  it  has  been  small  and  the  opening  in  the  bone  has 
been  made  of  corresponding  size  and  one  is  sure  that  all 
diseased  tissue  has  been  removed,  there  are  no  reasons  which 
should  prevent  the  closure  by  sutures  at  once,  so  that  healing 
by  primary  union  may  take  place.  For  this  purpose  silk  or 
silkworm  gut  is  best  and  the  edges  of  the  incision  should 
be  brought  into  as  close  apposition  as  possible  in  order  to  get 
a  good  cosmetic  result.  In  the  great  majority  of  cases,  how- 
ever, where  this  operation  is  performed  for  chronic  otorrhcea, 
the  primary  closure  of  the  wound  is  inadvisable,  as  one  can- 
not be  sure  that  all  diseased  bone  has  been  removed,  and  if, 
under  these  circumstances,  the  entire  wound  should  be 
sutured,  one  will  probably  have  a  fistula  forming  in  a  short 
time,  or  it  will  be  necessary  to  perform  a  secondary  opera- 
tion to  relieve  the  retained  secretion.  In  these  cases  it  is 
therefore  advisable,  if  the  incision  be  large,  to  place  one  or 
two  sutures  in  its  upper  angle  and  also  in  the  secondary 
horizontal  incision  if  such  has  been  made  in  order  to  obtain 

19 


274  Suppuration  of  the  Middle  Ear. 

a  smaller  cicatrix  and  to  prevent  a  slight  drooping  of  the 
auricle  which  sometimes  takes  place  if  this  be  not  done,  the 
rest  of  the  wound  directly  over  the  cavity  in  the  bone  then 
being  packed,  so  that  if  later  areas  of  carious  or  necrosed 
bone  should  be  found  they  can  readily  be  removed  without 
again  dividing  the  soft  tissues. 

The  method  of  Blake  of  allowing  the  bone  cavity  to  fill 
with  blood  clot  has  been  employed  in  a  few  cases,  but  as  a 
rule  it  is  not  desirable.  This  is  employed  in  cases  where  the 
opening  in  the  bone  is  small  in  size  and  when  the  inner  wall 
of  the  mastoid  remains  intact  and  is  recommended  by  the 
author  as  a  substitute  for  packing  and  healing  by  granula- 
tion. It  is  essential  to  the  success  of  this  method  that  all 
diseased  tissue  should  be  removed  and  the  cavity  is  then 
allowed  to  fill  with  blood  and  when  partial  coagulation  has 
taken  place  the  wound  is  sutured  in  its  entirety,  or  the  edges 
of  the  wound  are  brought  into  apposition  and  by  the  applica- 
tion of  fairly  firm  pressure  it  is  allowed  to  heal  by  first  inten- 
tion. Healing  then  takes  place  by  the  formation  of  granula- 
tion tissue  protected  by  the  clot  without  reaction,  and  at  the 
same  time  it  is  claimed  that  the  time  of  treatment  is  much 
shortened,  but  in  some  cases,  however,  the  blood  clot  is  apt 
to  become  infected  and  break  down,  so  that  healing  will  have 
to  ultimately  take  place  through  the  open  wound  by  granu- 
lation. When  the  wound  is  not  sutured  in  its  entirety,  but 
only  its  upper  and  lower  portion,  a  rubber  drainage  tube  may 
be  placed  well  into  the  small  bone  cavity,  as  it  is  only  in 
cases  where  the  opening  in  the  bone  is  small  that  drainage 
by  this  method  is  applicable  and  the  dressings  are  applied 
over  this.  In  the  majority  of  cases,  however,  this  method 
of  drainage  is  not  serviceable,  and  the  opening  in  the  bone 
should  be  packed  with  gauze.  After  cleansing  and  drying 
the  tissues,  the  cavity  is  lightly  dusted  with  iodoform  and 
packed  with  strips  of  iodoform  gauze,  the  packing,  however, 


The  Simple  Mastoid  Operation.  275 

not  being  too  tight  and  a  narrow  strip  of  the  gauze  packing 
being  allowed  to  project  between  the  edges  of  the  wound. 
The  external  auditory  canal  is  then  lightly  packed  in  the 
same  way  so  that  drainage  will  be  encouraged  and  not  in 
any  manner  obstructed.  The  mastoid  is  then  covered  with 
several  layers  of  iodof orm  gauze ;  this  in  turn  is  covered  with 
a  thick  layer  of  plain  sterile  gauze ;  over  this  is  placed  a  thick 
layer  of  cotton,  which  also  covers  the  entire  ear,  and  the 
dressings  are  then  held  in  place  by  a  muslin  or  gauze  bandage 
so  that  the  parts  are  thoroughly  protected. 

Opinions  vary  as  to  results  obtained  in  curing  the  otor- 
rhcea  by  this  operation,  some  otologists  believing  that  a  per- 
manent cure  is  seldom  obtained  by  this  method,  but  if  it  be 
used  in  a  small  selected  class  of  cases  of  chronic  aural  sup- 
puration, as  previously  described,  one  will  obtain  very  satis- 
factory results  in  a  considerable  proportion  of  cases,  depend- 
ing upon  the  thoroughness  with  which  the  limited  area  of 
diseased  tissue  is  removed,  for  even  in  the  radical  operation 
one  is  apt  to  be  disappointed  in  obtaining  a  perfect  cure  in 
many  cases,  Schmiegelow's  cases  showing  this  quite  clearly, 
as  in  ninety-six  cases  the  mastoid  apophysis  was  alone  opened 
in  twenty,  with  55  per  cent,  cured;  the  attic  was  opened  in 
fourteen  cases  with  seven  cures  and  three  improved,  while 
in  fifty- three  cases  the  entire  middle  ear  was  opened,  with 
70  per  cent,  of  cures.  The  continuation  of  the  otorrhoea 
following  this  operation  may  result  from  several  causes,  of 
which  the  principal  is  the  failure  to  remove  all  the  diseased 
bone,  but  in  some  this  results  from  performing  the  operation 
before  the  removal  of  the  carious  ossicles,  and  while  in  such 
cases  the  diseased  tissue  in  the  antrum  and  mastoid  process 
may  be  thoroughly  removed,  the  tympanic  suppuration  will 
continue  until  an  ossiculectomy  has  been  performed,  when  it 
will  usually  yield,  thus  implying  in  these  cases  that  the  tym- 
panic contents  should  be  removed  at  first,  when  this  failing, 


276  Suppuration  of  the  Middle  Ear. 

the  mastoid  operation  should  be  performed.  Finally,  in  cases 
of  chronic  suppurative  otitis  media,  should  both  ossiculec- 
tomy  and  simple  opening  of  the  mastoid  process  and  antrum 
fail  to  bring  about  the  cessation  of  the  purulent  discharge, 
the  evidence  is  then  in  favor  of  a  more  extensive  area  of 
caries  and  necrosis  than  originally  supposed  and  exenteration 
of  the  tympanic  and  mastoid  contents  must  be  performed. 


CHAPTER  IV. 

THE  RADICAL  MASTOID  OPERATION, 


277 


THE  RADICAL  MASTO1D  OPERATION. 

While  any  operative  procedure  which  is  performed  for 
the  cure  of  chronic  suppurative  otitis  media  is  based  upon 
the  removal  of  all  the  diseased  tissue,  the  radical  operation 
in  any  of  its  various  forms  or  modifications,  does  no  more 
than  this,  but  has  the  advantage  over  operation  via  the 
canal  or  the  simple  opening  of  the  antrum,  that  one  is  more 
certain  that  all  diseased  tissue  keeping  up  the  suppuration 
has  been  removed,  and  if  not,  the  dangers  of  extension  have 
been  greatly  lessened,  while  the  patient  has  been  placed  under 
such  favorable  conditions,  that  the  tympanum  and  its  neigh- 
boring spaces  are  freely  opened  to  local  treatment  through 
the  meatus  or  post-auricular  opening.  As  a  result  of  the 
better  understanding  of  the  pathology  of  chronic  otorrhcea, 
and  especially  with  the  knowledge  that  the  antrum  and  mas- 
toid  cells  are  involved  in  practically  all  cases  of  long  dura- 
tion, the  radical  operation  has  to  a  great  extent  supplanted 
more  conservative  measures  as  the  simple  opening  of  the 
antrum,  for,  as  has  been  shown  by  Macewan,  after  the  open- 
ing of  the  mastoid  antrum  at  its  usual  position,  further  pro- 
cedures have  purely  a  pathological  basis,  and  if  the  disease 

279 


280  Suppuration  of  the  Middle  Ear. 

revealed  be  extensive,  so  must  also  be  the  operation.  Al- 
though the  tympanic  exenteration  has  been  designated  the 
radical  operation,  yet  actually  this  is  only  relatively  so,  as  it 
may  be  impossible  to  remove  all  the  diseased  tissue  that  may 
extend  to  the  finer  cellular  spaces  in  all  parts  of  the  temporal 
bone,  and  while  in  the  majority  of  cases  sufficient  of  the  dis- 
eased tissue  may  be  removed  to  obtain  a  permanent  cessation 
of  the  purulent  discharge,  yet  in  many  instances  failure  of 
necessity  must  take  place.  As  stated  by  Green,  the  tympano- 
mastoid  exenteration,  that  is,  the  evisceration  of  the  interior 
of  the  bone  by  making  the  mastoid  cells,  antrum,  tympanum, 
attic  and  meatus  one  large  cavity  with  smooth  and  healthy 
walls  by  removing  the  external  cortex  of  the  mastoid,  its 
entire  cancellated  structure,  the  posterior  wall  of  the  meatus, 
the  membrana  tympani  and  ossicles  and  outer  wall  of  the 
epitympanum  is  the  most  valuable  operation  for  the  cure  of 
chronic  suppuration  here  and  it  is  also  one  of  the  most  com- 
plicated operations  in  surgery,  as  its  success  depends  upon 
the  attention  to  the  most  minute  details,  not  only  in  the  oper- 
ation itself,  but  in  the  after  treatment,  the  great  technical 
difficulties  being  the  thorough  cleansing  of  the  exenterated 
cavity,  the  covering  of  the  exposed  bone  surface,  the  keep- 
ing down  of  exuberant  granulation  tissue,  and  the  epidermi- 
zation  of  the  newly  formed  cavity.  Whatever  be  the  nature 
of  the  radical  operation  performed,  the  object  to  be  aimed  at 
is  the  same  in  all,  that  is,  the  throwing  together  of  the 
involved  parts  into  one  large  cavity  lined  with  a  nonsecreting 
dermoid  covering. 

The  indications  for  the  radical  operation  are  usually 
definite  in  the  presence  of  serious  symptoms  from  the  exten- 
sion of  the  suppurative  process,  but  when  the  question  con- 
cerns only  the  cure  of  the  otorrhoea,  great  difficulty  will  often 
arise  in  deciding  when  to  operate  and  the  nature  of  the  opera- 
tion to  be  performed.  Jackson  recommends  radical  opera- 


The  Radical  Mastoid  Operation.  281 

tion  in  the  absence  of  mastoid  symptoms  when  the  suppu- 
ration has  failed  to  yield  in  three  months  after  ossiculectomy 
followed  by  "wick  drainage."  Manasse  and  Wintermantel 
are  slow  to  employ  the  radical  operation  in  the  absence  of 
vital  indications,  while  Schwartze  believes  that  it  is  indi- 
cated as  a  prophylactic  against  fatal  results  developing  with- 
out any  visible  inflammation  of  the  mastoid  and  without 
signs  of  pus  retention,  whenever  it  is  proven  that  the  seat 
of  the  suppuration  is  not  limited  to  the  tympanum.  While 
each  case  must  be  decided  upon  the  particular  conditions 
present,  both  from  an  intrinsic  and  extrinsic  point  of  view, 
yet  certain  indications  when  present  strongly  suggest  the 
necessity  for  radical  operation,  these  being  more  or  less 
marked  in  various  cases.  As  regards  the  pathological 
changes  in  the  temporal  bone,  the  presence  of  caries,  as  shown 
by  the  recurrence  of  granulation  tissue  after  its  removal, 
fistula  in  the  mastoid  process,  antral  suppuration,  paralysis 
of  the  facial  nerve,  acute  mastoiditis  during  the  course  of 
the  tympanic  suppuration  and  suppuration  resisting  other 
treatment,  indicates  the  necessity  for  the  removal  of  the 
diseased  tissue  in  its  entirety.  Narrowing  or  actual  strict- 
ure of  the  external  canal  leading  to  pus  retention,  or  the 
presence  of  cholesteatoma  of  the  antrum  or  mastoid  undoubt- 
edly indicates  operation.  Politzer  does  not  advise  radical 
operation  simply  to  check  a  stubborn  otorrhcea,  because,  while 
the  operation  may  be  harmless,  there  is  a  possibility  of  injury 
to  the  neighboring  parts,  of  a  total  loss  of  hearing,  and  also 
that  the  time  required  for  healing  the  parts  places  the  patient 
hors  de  combat  for  several  months.  Cumberbatch  sums  up 
this  matter  quite  satisfactorily  when  he  states  that  the  opera- 
tion should  be  performed  when  a  frequent  recurring  dis- 
charge is  invariably  preceded  by  malaise,  slight  headache, 
rise  of  temperature  and  occasionally  mastoid  tenderness  and 
discomfort;  in  cases  where  previous  suppuration  has  been 


282  Suppuration  of  the  Middle  Ear. 

present,  but  has  given  no  trouble  for  years,  with  suddenly 
developed  marked  labyrinthine  vertigo,  due  to  the  spread  of 
the  inflammation  to  the  labyrinth,  or  pressure  from  some 
accumulation  in  that  region;  in  cases  of  intermittent  dis- 
charge, with  masses  of  sodden  epidermis  in  the  meatus,  often 
hiding  small  granulations,  and  where  syringing  constantly 
removes  white  shreddy  patches  and  the  usual  methods  of 
treatment  fail  to  cure;  and  finally,  when  there  are  periodic 
attacks  of  mastoid  pain  commencing  after  all  signs  of  active 
mischief  in  the  ear  have  ceased,  and  where  by  exclusion  of 
superficial  neuralgia  it  is  possible  to  determine  the  existence 
of  sclerosing  osteitis.  Ballance  states  that  in  another  class 
of  cases  with  no  mastoidal  or  other  signs,  in  which  removal 
of  the  ossicles,  antiseptic  dressings,  etc.,  fail,  and  the  dis- 
charge, either  offensive  or  odorless,  persists,  a  wide  expe- 
rience is  the  best  guide,  as  no  definite  indications  can  be 
formulated,  while  Lucae  in  such  cases  believes  that  when 
one  is  in  doubt,  it  is  better  to  operate,  and  Grant  thinks  the 
responsibility  is  greater  in  deciding  against  than  in  deciding 
in  favor  of  the  operation.  Koerner  has  pointed  out  that  the 
radical  operation  is  indicated  as  soon  as  the  diagnosis  of 
chronic  suppuration  is  made  and  when  the  diagnosis  of  bone 
involvement  is  uncertain,  the  operation  should  be  done  as 
soon  as  there  are  symptoms  of  pus  retention,  while  Dalby 
has  summed  up  these  indications  as  follows:  (i)  Undoubt- 
edly where  septicemia  has  commenced.  (2)  Undoubtedly 
where  dead  or  carious  bone  in  the  tympanic  cavity  is  accom- 
panied by  ominous  symptoms  often  repeated.  (3)  When- 
ever there  is  evidence  of  mastoid  disease  of  longer  or  shorter 
standing.  (4)  In  a  certain  proportion  of  cases  where  there 
is  dead  or  diseased  bone,  but  a  very  doubtful  history  of 
ominous  symptoms.  (5)  In  a  certain  proportion  of  cases 
with  intractable  otorrhcea,  where  no  bone  disease  can  be 
found  and  no  history  of  ominous  symptoms. 


EXPLANATORY   NOTE   TO    PLATE   XXX. 


This  plate  shows  the  completed  radical  (Stacke-Schwartze)  operation  on  a  bone 
specimen. 

i,  Mastoid  antrum  and  attic  opened  and  aditus  ad  antrum  enlarged;  2,  region  of 
horizontal  semicircular  canal ;  3,  bony  spine  remaining  after  the  removal  of  the  osseous 
posterior  canal  wall ;  4,  the  floor  of  the  external  auditory  canal ;  5,  terminal  (tip) 
cell ;  6,  cells  opened  at  the  root  of  the  zygomatic  process. 

284 


PLATE  XXX 


The  Radical  Mastoid  Operation.  285 

The  objects  of  the  radical  operation  essentially  consist  in 
throwing  all  the  middle  ear  cavities  into  one  (see  plate  XXX), 
of  removing  all  the  diseased  tissue  of  whatever  nature,  and  of 
rendering  the  cavity  so  formed  readily  accessible  to  treatment, 
thus  promoting  both  the  rapid  and  fairly  certain  cessation  of 
the  suppuration.  Certain  advantages  are  also  obtained  in  this 
way  that  render  it  practically  the  ideal  operation  for  the  cure 
of  the  tympanic  suppuration.  By  throwing  these  cavities  into 
one  space  it  exposes  the  previously  diseased  areas  to  the  sight 
of  the  operator  and  allows  him  to  immediately  destroy  any 
new  focus  of  disease  which  may  subsequently  form,  either 
of  the  lining  membrane  or  of  the  osseous  walls  of  this  cavity ; 
the  parts  may  be  kept  in  a  more  aseptic  condition  than  can 
be  obtained  in  any  of  the  other  operations  previously  dis- 
cussed, and  further,  its  advantages  over  operative  treatment 
by  way  of  the  canal  consists  in  the  facility  by  which  one  is 
enabled  to  obtain  a  strong  barrier  against  the  extension  of 
the  purulent  changes  to  other  parts.  Over  the  simple  open- 
ing of  the  antrum  it  allows  one  to  remove  all  the  macroscopic 
diseased  tissue  and  to  have  perfectly  under  control  any 
further  marked  morbid  changes,  such  as  small  areas  of 
caries,  or  the  throwing  off  of  a  larger  or  smaller  sequestrum 
which  may  take  place,  or  more  extended  pathological  altera- 
tions occurring  in  the  bone  which  had  not  been  removed  at 
the  time  of  operation.  By  opening  the  parts  in  the  manner 
to  be  later  described,  anatomical  conditions  are  produced 
which  most  materially  diminish  further  risks  of  purulent 
retention.  While  in  some  cases  it  may  be  possible  to  remove 
the  cause  of  the  suppuration  by  way  of  the  canal,  yet  on 
account  of  its  location  this  may  be  extremely  hazardous,  and 
as  a  matter  of  safety,  the  radical  opening  of  the  mastoid  may 
be  necessary,  and  even  should  this  method  fail  to  produce 
a  nonsecreting  lining  to  the  newly  made  cavity,  it  possesses 
the  advantage  that  the  patient  is  left  in  a  much  safer  con- 


286  Suppuration  of  the  Middle  Ear. 

dition  than  before,  inasmuch  as  the  parts  can  be  locally 
treated  with  considerable  accuracy  and  all  foci  for  purulent 
collection  and  retention  can  no  longer  exist. 

In  considering  the  conditions  which  may  seem  to  indicate 
the  radical  operation,  especially  when  the  aural  lesions  do 
not  appear  to  be  extensive  and  the  symptoms  are  not  well 
marked,  one  must  always  bear  in  mind  that  under  these  con- 
ditions the  operation  possesses  certain  disadvantages  which 
may  militate  against  its  performance.  Such  is  the  case  when 
the  social  condition  of  the  patient  prevents  him  from  being 
self-supporting  for  weeks,  or  possibly  several  months,  as  this 
operation  necessitates  in  many  cases  the  relinquishment  of 
labor  for  that  time,  and  again,  if  the  patient  depends  for  his 
livelihood  to  any  extent  upon  his  hearing,  this  will  have  to 
be  seriously  considered,  as  it  is  not  at  all  uncommon  to  have 
the  hearing  seriously  impaired  following  operation.  While 
a  question  that  must  always  be  considered  in  such  cases,  is 
that  in  this  operation  there  is  always  a  considerable  pro- 
portion of  failures  as  regards  the  cessation  of  the  suppu- 
ration, and  the  patient  should  be  fully  advised  of  this  previous 
to  the  performance  of  the  operation.  These  disadvantages 
of  course  do  not  in  any  manner  apply  to  those  cases  where 
the  patient  desires  to  obtain  relief  from  the  otorrhoea  when 
symptoms  of  serious  importance  are  also  present,  but  it  is 
only  in  the  absence  of  these  that  such  questions  will  arise. 

In  this  chapter  two  forms  of  the  radical  operation  will 
be  considered,  the  various  modifications  being  described 
later,  and  of  these  the  Stacke  or  the  Stacke-Schwartze  must 
be  selected  by  the  conditions  present  in  each  case,  many  oper- 
ators preferring  the  former,  but  possibly  more  see  greater 
advantages  in  the  latter.  While  it  is  almost  impossible  to 
estimate  their  relative  value  as  compared  one  with  the  other, 
on  account  of  the  pathological  complex  in  each  case  operated 
upon,  yet  some  idea  of  their  relative  value  may  be  obtained 


The  Radical  Mastoid  Operation.  287 

by  the  statistics  of  Milligan,  who  had  sixty-five  recoveries  in 
seventy-eight  Stacke-Schwartze's,  while  in  the  former  there 
were  forty-seven  recoveries  in  seventy-two  operations.  In 
the  Stacke  operation  the  antrum  is  entered  from  in  front  of 
the  posterior  canal  wall  backwards,  while  in  the  other  pro- 
cedure, which  is  sometimes  also  called  the  Zauf  al  method,  the 
antrum  is  opened  in  the  usual  manner  through  the  mastoid 
process,  as  will  be  later  described.  The  method  recom- 
mended by  Stacke  for  the  radical  cure  of  the  chronic  aural 
suppuration  consists  in  making  the  usual  incision  over  the 
mastoid  process,  in  detaching  the  external  cartilaginous 
canal  and  auricle  and  chiseling  away  the  postero-superior 
osseous  wall  of  the  auditory  canal  with  the  external  attic 
wall,  so  that  both  the  attic  and  antrum  are  freely  exposed, 
and  these  parts  are  thrown  into  one  large  smooth  cavity 
without  any  osseous  projections.  Thus  this  operation  is 
performed  within  the  osseous  canal,  and  by  removing  con- 
centric layers  of  bone  the  operative  field  may  be  enlarged 
to  any  extent  desired,  dependent  entirely  upon  the  extent 
of  the  morbid  changes  which  are  found  and  the  involved  cel- 
lular spaces  are  cut  away  until  healthy  bone  is  reached,  when 
flaps  are  then  made  from  the  cartilaginous  canal,  both  in 
order  to  obtain  a  healthy  nonsecreting  epithelial  surface 
over  the  newly  exposed  bone  and  to  prevent  cicatricial  con- 
traction of  the  auditory  canal,  the  after  treatment  being  con- 
ducted through  the  meatus  to  the  large  cavity  which  is 
under  observation  in  all  its  parts.  This  method  possesses 
certain  advantages,  as  it  gives  full  ingress  to  the  deeper  parts 
when  the  cartilaginous  meatus  has  been  removed,  and  one 
then  obtains  a  maximum  amount  of  space  in  which  to  remove 
the  diseased  bone  and  enter  the  attic  and  antrum,  while  the 
ossicles  or  their  remains  are  readily  extracted.  The  Stacke 
operation  should  be  preferred  when  the  groove  of  the  lateral 
sinus  projects  far  forward,  as  one  practically  keeps  away 


288  Suppuration  of  the  Middle  Ear. 

from  danger  under  these  conditions,  while  in  the  Schwartze 
operation,  under  such  circumstances,  the  danger  of  wound- 
ing the  sinus  is  greatly  enhanced,  or  in  some  cases  for  this 
reason  the  latter  method  of  opening  the  antrum  becomes 
impossible. 

While  the  general  indications  for  the  radical  operation 
have  been  described,  certain  special  indications  exist  which 
are  in  favor  of  the  Stacke  method.  While  Politzer  states  that 
this  operation  is  too  radical  for  the  removal  of  the  ossicles 
alone,  which  is  undoubtedly  true,  it  is  far  superior  to  intra- 
aural  methods  for  removing  granulations  and  cholesteato- 
matous  masses  from  the  attic  and  its  real  indication  is  in 
those  cases  where,  besides  the  ossicles,  other  parts  of  the 
temporal  bone  are  diseased.  It  is  also  specially  indicated, 
as  before  mentioned,  when  the  sinus  is  pushed  forward  as 
the  result  of  an  anatomical  abnormality  or  mastoid  sclerosis, 
and  when  it  is  only  necessary  to  expose  the  attic  and  antrum, 
as  under  such  circumstances  the  removal  of  osseous  tissue 
is  small  and  the  damage  to  the  hearing  is  less  than  in  the 
more  extensive  radical  operation.  When  the  diseased  area 
is  large,  the  Stacke  method  is  objectional  and  presents  the 
disadvantage  that  an  excessive  amount  of  tissue  is  destroyed, 
and  further,  it  presents  the  danger  of  injuring  the  facial 
nerve,  the  horizontal  semicircular  canal  and  the  stapes. 
While  in  many  cases  this  operation  is  not  followed  by  suc- 
cessful results,  because  the  carious  process  is  more  extensive 
than  is  comprehended  in  the  usual  Stacke  procedure  and  is 
not  removed  in  this  manner,  although  this  can  hardly  be 
cited  as  a  fault  against  this  particular  procedure,  but  should 
rather  be  considered  as  the  result  of  an  error  in  diagnosis, 
whereby  the  post-aural  operation  was  not  performed  origi- 
nally in  such  cases  as  it  should  be.  For  cholesteatomatous 
masses,  limited  to  the  attic  and  antrum,  this  procedure  is  well 
suited,  as  it  leaves  no  permanent  external  wound,  and  yet  by 


The  Radical  Mastoid  Operation.  289 

cutting  away  the  external  wall  of  these  spaces  one  is  in  a 
position  to  inspect  and  treat  the  exposed  spaces.  But  when 
a  large  defined  cholesteatoma  is  present,  involving  not  only 
these  parts  but  also  the  mastoid  process  and  possibly  ex- 
posing the  meninges,  this  operation  alone  will  not  suffice  for 
its  cure,  and  in  such  cases  the  Stacke-Schwartze  procedure 
should  be  adopted,  so  that  the  parts  may  be  carefully  observed 
through  the  permanent  retroauricular  opening.  While  the 
Stacke  operation  is  applicable  in  many  cases,  as  already  out- 
lined, it  should  not  be  employed  when  the  carious  process  of 
the  mastoid  has  extended  to  the  surface  and  resulted  in  a 
fistula,  or  when  there  are  well-defined  symptoms  of  a  mastoid 
abscess.  While  in  cases  where  it  is  supposed  that  the  destruc- 
tion of  the  mastoid  interior  is  very  extensive,  even  if  but 
slight  symptoms  be  present,  or  in  those  cases  where  the  ex- 
ternal auditory  canal  has  been  greatly  narrowed  or  an  actual 
stricture  exists,  some  other  form  of  the  radical  operation 
should  be  employed  in  preference  to  the  Stacke. 

The  primary  step  in  the  Stacke  operation  is  the  incision 
through  the  soft  tissues  over  the  mastoid  process  and  differs 
but  little  from  that  already  described  for  the  simple  open- 
ing of  the  antrum.  The  incision  should  be  curved,  com- 
mencing anteriorly  at  the  temporal  region  slightly  above  the 
auricle  and  should  be  carried  downwards  close  to  the  pinna, 
to  a  point  about  a  centimeter  below  the  tip  of  the  mastoid 
process.  It  should  cut  through  all  the  overlying  tissues  down 
to  the  bone.  At  its  upper  extremity  this  is  sometimes  mod- 
ified by  dissecting  loose  the  soft  parts  above  the  temporal 
ridge  superficial  to  the  temporal  fascia,  and  from  the  ridge 
downwards,  the  original  incision  which  in  its  upper  ex- 
tremity should  extend  only  through  the  skin  and  superficial 
fascia,  the  first  incision  is  extended  through  the  periosteum 
and  slightly  along  the  temporal  line,  so  that  a  triangular  flap 
of  the  periosteum  is  thus  made  which  can  be  readily  pushed 

20 


290  Suppuration  of  the  Middle  Ear. 

forward  to  the  edge  of  the  osseous  canal.  After  the  bone 
has  been  exposed  the  periosteum  of  the  anterior  flap  is  pushed 
forward  with  the  elevator,  so  that  the  canal  and  posterior 
portion  of  the  zygomatic  root  is  clearly  exposed  to  view,  and 
with  it  the  dermal  lining  of  the  cartilaginous  canal.  With 
a  small  elevator  the  periosteum  is  separated  from  the  walls 
of  the  auditory  canal  as  far  into  the  meatus  as  possible, 
and  when  this  is  done,  it  will  be  found  that  the  soft  tissues 
of  the  canal  have  been  entirely  detached  from  the  underly- 
ing bone,  except  at  their  inner  and  anterior  portions.  With 
a  small  knife  the  entire  canal  is  divided  transversely  as  near 
the  membrana  as  possible.  By  then  drawing  the  auricle  out- 
wards and  forwards  the  still  adherent  anterior  attachments 
may  be  severed,  and  the  entire  cartilaginous  canal,  including 
the  auricle  and  a  considerable  portion  of  the  inner  dermal 
lining,  may  be  drawn  completely  outwards,  so  that  the  osseous 
portion  of  the  canal  and  the  tympanum  are  free  and  readily 
seen.  The  auricle  with  its  attached  canal  is  then  held  for- 
wards and  out  of  the  way  with  a  retractor  and  the  remnants 
of  the  membrana  tympani  with  the  malleus  are  then  removed 
in  the  manner  previously  described,  if  they  have  not  pre- 
viously been  removed  by  operation  through  the  canal.  If 
the  ossicles  are  present,  at  least  in  part,  the  incus  may  also 
come  away  at  the  same  time  as  the  malleus  is  removed,  but 
if  this  does  not  take  place,  then  it  is  advisable  to  leave  the 
former  ossicle  until  a  later  step.  A  probe,  or  preferably 
Stacke's  protector,  is  then  held  in  place  in  the  attic,  and  then 
with  the  gouge  or  chisel  placed  a  few  millimeters  above  the 
edge  of  the  epitympanum,  holding  the  instrument  used 
slightly  backwards,  the  bone  here  is  removed  while  the  pro- 
tector may  be  used  as  a  guide.  The  osseous  tissue  of  the 
external  attic  wall  corresponding  to  the  superior  and  pos- 
terior margins  of  the  bony  canal,  should  thus  be  carefully 
removed,  measuring  the  depth  of  the  attic  from  time  to  time 


The  Radical  Mastoid  Operation.  291 

with  a  bent  probe  until  the  tegmen  tympani  and  the  superior 
wall  of  the  meatus  are  perfectly  smooth  and  continuous. 
After  the  attic  has  thus  been  freely  exposed,  the  incus,  if 
present,  is  removed,  and  with  the  protector  still  covering 
the  stapes,  it  is  pushed  backwards  as  a  guide  into  the  aditus 
and  the  osseous  tissue  of  the  tympanic  margin  and  this 
angle  of  the  canal  is  cut  away  until  the  probe  or  the  protector 
can  readily  enter  the  antrum.  The  facial  nerve  and  semi- 
circular canal  are  then  protected  by  the  instrument,  and  with 
the  chisel  the  osseous  tissue  external  to  the  antrum  is  cut 
away.  By  doing  this  one  removes  a  part  of  the  cortex  and 
the  posterior  canal  wall  in  its  lateral  portion  and  thus  con- 
verts the  antrum  into  a  narrow  trough  which  forms  a  single 
large  cavity  with  the  auditory  canal  and  attic.  In  removing 
this  area  of  bone  external  to  the  antrum,  quite  large  pieces 
may  be  cut  away  with  the  chisel  and  all  the  bone  should  be 
obliterated  here,  so  that  the  lower  wall  of  the  antrum  becomes 
continuous  with  the  inferior  wall  of  the  external  canal. 
While  performing  this  part  of  the  operation,  one  has  gained 
from  the  removal  of  bone  in  entering  the  antrum  a  knowl- 
edge of  its  position  and  size  and  therefore  can  work  with  a 
great  degree  of  confidence,  and  when  this  cavity  has  been 
thrown  into  one  with  the  canal,  its  upper  and  lower  osseous 
walls  will  be  smoothly  continuous  with  those  of  the  latter. 

The  small  spur  which  guards  the  entrance  between  the 
attic  and  antrum  should  be  made  perfectly  smooth  and  the 
facial  prominence  or  spur  must  in  part  be  very  carefully 
lessened  in  size  until  it  becomes  assimilated,  as  it  will  laterally 
in  the  lower  canal  wall.  In  exposing  the  attic,  as  has  been 
shown  by  Hartmann,  it  is  necessary  to  penetrate  the  supero- 
posterior  wall  of  the  osseous  canal,  rather  than  the  posterior, 
which  is  too  near  the  facial  canal  to  permit  of  free  incisions, 
but  in  regard  to  the  facial  nerve  and  semicircular  canal,  it  is 
desired  to  consider  them  later,  after  describing  the  Stacke- 


292  Suppuration  of  the  Middle  Ear. 

Schwartze  operation  in  connection  with  their  relation  to  the 
radical  operation  in  general.  After  the  tympanum,  attic  and 
external  auditory  canal  have  been  exposed  and  made  to  com- 
municate with  each  other,  as  described,  the  pathological  tis- 
sue is  removed  with  the  curette,  care  being  taken  to  avoid 
the  stapes  when  the  tympanic  cavity  is  being  curetted,  and  if 
caries  is  present  on  the  tympanic  floor,  the  ridge  of  bone 
here  should  be  broken  down  and  the  hypotympanum  carefully 
curetted.  The  mastoid  cells  are  then  broken  down,  if  such 
be  necessary,  and  the  diseased  tissue  in  all  parts  of  the  large 
cavity  thus  formed  should  be  thoroughly  removed,  and  any 
irregularity  of  its  walls  obliterated,  when  the  plastic  portion 
of  the  operation  should  be  performed,  as  will  be  later  de- 
scribed in  connection  with  the  plastic  methods  of  the  Stacke- 
Schwartze  operation. 

The  Stacke-Schwartze  operation,  which  is  a  combination 
of  the  Stacke  method  and  the  opening  of  the  mastoid  antrum 
through  the  cortex,  the  antrum  being  opened  in  the  usual 
manner,  and  after  the  posterior  wall  of  the  auditory  canal 
has  been  removed,  the  cavities  are  thrown  into  communi- 
cation after  the  method  of  Stacke,  the  membranous  canal 
not  being  entirely  withdrawn  from  the  canal  but  its  anterior 
half  is  allowed  to  remain  undisturbed,  the  objects  of  this 
operation  differing  in  no  way  from  that  of  the  former  of 
removing  all  the  pathological  tissue  and  throwing  the  affected 
cavities  into  one  chamber,  but  its  method  of  doing  this  varies, 
as  will  be  seen.  When  the  diseased  process  is  somewhat 
extensive,  this  procedure  possesses  the  advantages  over  the 
Stacke  and  other  similar  operations  in  that  it  furnishes  a 
large  space  in  which  to  operate,  giving  the  maximum  amount 
of  space  that  can  be  obtained  here,  and  it  also  enables  one 
to  freely  determine  the  extent  and  character  of  the  tissue 
changes  in  the  antrum  and  mastoid  process,  so  that  one  can 
very  accurately  ascertain  the  amount  of  morbid  tissue  which 


The  Radical  Mastoid  Operation.  293 

it  may  be  necessary  to  remove.  If  the  lateral  sinus  be  not 
too  far  forward,  it  enables  one  to  more  safely  and  thoroughly 
expose  the  sinus  if  parts  of  its  osseous  walls  be  carious  and 
the  same  advantages  are  also  to  be  noted  in  removing  the 
tegmen  tympani  or  carious  bone  in  its  immediate  vicinity, 
while  in  many  cases  a  more  satisfactory  plastic  operation 
can  be  performed  after  this  operation  than  with  the  Stacke 
procedure.  The  thoroughness  with  which  the  diseased  tissue 
can  be  removed  and  the  cause  of  the  chronic  suppurative 
otitis  media  be  eradicated  makes  this  a  most  favorable  opera- 
tive procedure  for  such  cases,  and  by  many  otologists  it  is 
considered  the  radical  operation  par  excellence.  Compared 
with  the  other  radical  procedures,  the  following  steps  are 
carried  out  in  performing  this  operation:  the  exposure  of 
the  operative  field,  the  removal  of  the  posterior-superior 
lining  of  the  external  auditory  canal,  opening  the  antrum  by 
entering  the  mastoid  process  through  the  usual  situation  on 
the  cortex,  and  by  removing  the  posterior  wall  of  the  osseous 
canal,  the  extirpation  of  the  external  wall  of  the  attic,  the 
removal  of  the  tympanic  and  mastoid  contents  and  throwing 
these  cavities  into  a  single  uninterrupted  space,  and  finally 
the  plastic  method  and  dressing  of  the  wound,  including 
skin  grafting  or  not  as  may  be  necessary  in  the  individual 
case. 

The  primary  incision  over  the  mastoid  varies  to  some 
extent  in  the  hands  of  different  operators,  but  the  principle 
involved  in  all  is  to  obtain  a  free  operative  field  by  a  liberal 
dissection  of  the  soft  parts.  As  a  rule  the  incision  should 
begin  immediately  above  the  superior  attachment  of  the 
pinna,  and  extending  three  or  four  millimeters  behind  and 
parallel  to  the  auricle,  should  reach  the  tip  of  the  mastoid. 
It  should  be  made  slightly  concave  in  the  anterior  direction 
and  at  its  beginning  over  the  temporal  muscle,  it  should 
extend  only  through  the  skin  and  superficial  fascia,  as 


294  Suppuration  of  the  Middle  Ear. 

nothing  is  to  be  gained  by  cutting  into  the  muscle  and  trou- 
blesome bleeding  takes  place,  which  may  be  productive  of 
considerable  annoyance,  while  further  down  over  the  mas- 
toid  process  the  incision  should  extend  to  the  bone.  As  in- 
sisted on  by  Politzer,  the  incision  is  carried  down  near  the 
insertion  of  the  auricle  over  the  meatus,  and  the  knife  should 
be  held  at  right  angles  to  the  planum  to  avoid  cutting  the 
posterior  membranous  wall  of  the  auditory  canal,  for  if  this 
should  be  thus  accidentally  damaged,  the  proper  plastic  oper- 
ation cannot  be  performed.  This  is  liable  to  happen  quite 
readily,  as  when  the  auricle  is  pulled  forwards,  as  may  some- 
times be  done  to  put  it  on  the  stretch  for  the  incision,  its  line 
of  insertion  is  pulled  more  anteriorly,  the  incision  being 
made  so  that  the  skin,  with  the  subcutaneous  tissue  and  the 
posterior  muscular  fibers  of  the  auricle  are  cut  through,  in- 
cluding the  periosteum,  or  this  may  be  cut  through  by  a 
second  incision.  Again,  the  incision  may  be  made  so  that 
its  upper  end  is  above  and  then  in  a  direction  downwards  to 
slightly  above  the  tragus,  while  its  inferior  extremity  is 
brought  forwards  around  the  lobule  and  is  made  to  terminate 
immediately  below  the  antitragus,  but  this  leaves  a  some- 
what conspicuous  scar,  which  should  be  avoided  as  much  as 
possible  in  operating.  When  the  entire  mastoid  surface 
back,  near  the  middle  of  the  mastoid  and  extending  a  cen- 
timeter or  more  above  the  temporal  line  to  the  same  dis- 
tance below  the  tip  of  the  mastoid,  and  from  the  upper  end 
of  this  incision  a  second  horizontal  incision  is  made,  extend- 
ing three  or  four  centimeters  both  anteriorly  and  posteriorly, 
so  that  by  turning  backwards  and  forwards  these  flaps,  com- 
posed of  both  the  skin  and  periosteum,  the  entire  mastoid 
cortex  is  exposed.  When  the  incision  previously  described 
is  employed,  it  is  necessary,  if  sufficient  room  has  not  been 
obtained,  or  if  the  skin  over  the  mastoid  is  much  thickened 
from  inflammatory  infiltration,  to  make  a  second  incision 


The  Radical  Mastoid  Operation.  295 

backwards  at  right  angles  to  the  first,  or  if  this  be  not  desired, 
the  original  incision  may  be  enlarged,  both  above  and  below. 
One  should  be  cautious  in  making  the  original  incision  that 
it  should  not  be  placed  too  close  to  the  insertion  of  the 
auricle,  for  fear  of  not  obtaining  sufficient  exposure  of  the 
anterior  edge  of  the  mastoid,  for  if  this  be  done,  it  will  be 
necessary  to  make  another  incision  at  right  angles  to  this 
one,  or  to  undermine  the  posterior  flap,  which  is  very  unsat- 
isfactory and  rarely  give  sufficient  room  for  working.  In 
all  cases  the  upper  end  of  the  incision  should  be  inclined  in 
a  horizontal  direction  or  somewhat  forward  and  downward 
over  the  top  of  the  insertion  of  the  auricle,  so  that  the  upper 
wall  of  the  osseous  meatus  will  be  thoroughly  exposed,  and 
this  is  also  necessary  in  order  to  obtain  sufficient  room  to 
remove  the  external  epitympanic  wall.  In  certain  cases  it 
may  be  necessary  to  modify  the  original  incision,  the  most 
frequent  of  these  local  conditions  necessitating  this,  being 
described  by  Politzer  as  follows :  ( I )  In  diffuse  fluctuating 
subperiosteal  abscesses,  before  making  the  incision,  he  evac- 
uates the  pus  with  a  trocar  and  cannula  and  washes  out  the 
abscess  cavity,  while  after  incising  the  soft  tissues,  the  gran- 
ulation tissue  in  the  abscess  cavity  is  scraped  out  with  a 
large  sharp  curette  before  the  chiseling  of  the  osseous  tissue 
is  commenced.  (2)  If  there  is  a  fistula  on  the  mastoid 
process,  the  incision,  if  possible,  is  made  through  it,  and  after 
the  soft  parts  are  dissected  free  the  callous  edges  of  the 
fistula  are  excised  with  curved  scissors.  (3)  When  it  is 
found  that  there  are  abnormally  firm  adhesions  of  a  much- 
thickened,  tendinous-like  periosteum  to  the  planum  mas- 
toideum  and  the  circumference  of  the  external  auditory 
canal,  it  is  seldom  possible  to  loosen  the  periosteum  with  the 
sharp  elevator  and  to  avoid  tearing  it  should  be  carefully 
dissected  away  from  the  bone  with  a  scalpel  and  forceps. 
After  the  incision  through  the  soft  parts  has  been  com- 


296  Suppuration  of  the  Middle  Ear. 

pleted,  the  periosteum  of  the  posterior  flap  is  separated  from 
the  bone  and  pushed  backwards,  while  with  the  elevator  the 
periosteum  of  the  anterior  part  of  the  mastoid  is  handled 
in  the  same  way,  so  that  the  planum  mastoideum  is  perfectly 
free.  The  anterior  periosteal  flap  should  be  freely  dissected 
up  until  the  landmarks  previously  described  are  readily  seen 
and  the  spina  with  the  postero-superior  wall  of  the  osseous 
canal  are  entirely  clear.  In  some  cases,  where  the  perios- 
teum is  somewhat  thick  and  adherent  at  this  point,  it  will  be 
almost  impossible  to  push  it  out  of  the  way  as  desired,  and 
it  is  often  necessary  to  make  a  small  horizontal  incision 
through  the  fibrous  tissue  directly  above  this  point,  so  that 
it  meets  posteriorly  the  original  vertical  incision  and  the 
periosteal  flap  thus  obtained  can  be  readily  pushed  aside 
in  order  to  have  a  clear  operative  field.  When  the  perios- 
teum has  thus  been  pushed  aside  and  the  wall  of  the  meatus 
becomes  visible,  a  narrow  elevator  is  introduced  into  the 
osseous  external  canal  and  the  membraneous  meatus  is  de- 
tached from  the  bony  wall  at  its  superior  and  posterior  por- 
tion, until  it  is  entirely  free  at  these  parts  clear  to  the  tym- 
panic membrane.  To  accomplish  this  the  cartilaginous  canal 
and  auricle  should  be  drawn  well  forwards,  so  that  the  tissues 
may  be  cleanly  stripped  from  the  bone  and  the  inner  ex- 
tremity of  the  membraneous  tube  seen  in  order  that  the  next 
step  of  the  operation  may  be  readily  accomplished.  The 
fibrous  meatus,  which  is  then  drawn  well  forward  and  out- 
ward, is  divided  at  its  posterior  part  with  a  straight  sharp 
knife,  as  near  to  the  annulus  as  possible,  or  this  may  be 
accomplished  by  the  use  of  an  angular  knife,  cutting  from 
within  the  meatus  posteriorly.  Another  method  of  sepa- 
rating the  membraneous  meatus  at  this  point  is  accomplished 
by  making  an  incision  in  the  upper  anterior  wall  of  the 
meatus,  commencing  at  the  annulus  tympanicus  and  from 
within  outwards ;  a  like  incision  is  then  made  along  the  lower 


The  Radical  Mastoid  Operation.  297 

part  of  the  posterior  meatal  wall,  parallel  and  opposite  to 
the  first  incision  and  the  flap  of  tissue  thus  included  between 
these  two  incisions  is  separated  from  the  osseous  wall  and 
removed  with  scissors,  so  that  the  posterior  and  superior 
walls  of  the  canal  are  thus  exposed.  This  method  may, 
however,  seriously  interfere  with  any  plastic  operation  that 
may  be  desired,  and  for  this  reason  seems  to  be  usually  unde- 
sirable. A  further  method,  which  is  somewhat  extensively 
employed  and  which  obviates  the  cutting  of  the  canal  wall, 
consists  in  making  firm  but  careful  traction  upon  the  mem- 
braneous meatus,  so  that  the  canal  may  be  separated  at  its 
inner  superior  and  posterior  extremity  with  the  aid  of  the 
smallest  elevator,  so  that  it  becomes  detached  at  the  parts 
indicated  very  close  to  its  insertion  at  the  annulus.  Unlike 
the  Stacke  procedure,  the  canal  must  not  be  detached  at  its 
inferior  and  anterior  relations  with  the  bone,  as  in  this  opera- 
tion it  is  entirely  unnecessary  and  from  these  two  points  it 
is  desired  that  the  eviscerated  tympanum  and  other  cavities 
should  receive  their  epidermal  lining,  the  spreading  of  the 
epidermis  for  this  purpose  taking  place  from  the  canal  at 
these  points.  After  the  canal  has  thus  been  separated  from 
these  walls  of  the  osseous  meatus,  it  should  be  held  well 
forward  against  the  anterior  wall  by  a  narrow  retractor 
placed  between  it  and  the  posterior  wall,  and  when  the  bone  of 
the  mastoid  and  the  posterior  canal  wall  have  been  removed 
well  inward,  this  may  be  removed  and  the  usual  retractor 
for  the  anterior  flap  is  employed  in  its  place.  If  this  is  not 
desired,  some  operators  prefer  to  hold  these  parts  away  from 
the  operative  field  by  passing  a  strip  of  tape  or  gauze  through 
the  canal  and  holding  it  out  of  the  way  in  this  manner,  which 
is  usually  satisfactory  if  the  walls  of  the  membraneous  canal 
are  fairly  normal,  but  should  they  be  inflamed  or  much  mac- 
erated from  the  purulent  secretion,  this  method  of  retrac- 
tion cannot  be  employed  for  fear  of  tearing  the  soft  tissue 
from  the  force  necessary  to  keep  them  drawn  well  forward. 


298  Suppuration  of  the  Middle  Ear. 

The  osseous  field  being  then  freely  exposed  and  the  supra- 
meatal  triangle  being  taken  if  possible  for  the  guide,  the 
mastoid  is  entered  as  in  the  simple  operation  until  the  antrum 
has  been  opened,  or  instead  of  confining  the  removal  of  the 
osseous  tissue  to  this  space  alone,  the  bone  may  be  chiseled 
away  from  this  position  in  a  direction  forward  and  embrac- 
ing the  posterior  wall  of  the  anditory  canal,  the  removal  of 
the  bone  being  continued  until  the  groove  in  the  bone  thus 
formed  unites  the  antrum  with  the  tympanum  and  external 
surface  and  the  remains  of  the  tympanic  membrane  can  be 
seen.  It  is  unnecessary  to  redescribe  the  method  of  open- 
ing the  antrum  without  breaking  down  the  posterior  canal 
wall,  as  this  has  previously  been  done,  and  it  differs  in  no 
way  from  that  mentioned,  the  removal  of  the  posterior  wall, 
however,  from  this  side  being  the  characteristic  feature  of 
this  operation.  Should  the  mastoid  cortex  show  a  softened 
area  of  bone  or  a  fistula,  it  is  the  habit  of  some  operators 
to  commence  the  removal  of  bone  at  such  a  point  and  then 
work  towards  the  antrum,  but  this  is  not  always  advisable, 
and  as  has  been  previously  stated,  it  is  always  best  to  enter 
the  antrum  at  the  point  of  election,  and  after  this  has  been 
accomplished,  attention  may  be  directed  to  the  external  lesion 
during  the  course  of  the  mastoid  evisceration.  Should  the 
surface  of  the  process  show  no  lesion,  which  is  by  far  the 
usual  condition  in  these  chronic  cases,  one  may  with  the 
straight  and  curved  chisel  remove  the  bone  over  the  region  of 
the  mastoid  and  supero-posterior  wall  of  the  canal,  with  the 
small  area  of  the  opening  in  the  bone  above  and  then  by  re- 
moving successive  layers  of  bone,  the  antrum  may  be  entered 
and  this  portion  of  the  canal  wall  broken  down  as  desired,  so 
that  as  the  opening  is  made  deeper  into  the  bone,  the  parts  are 
constantly  kept  in  view.  This  should  form  a  somewhat  cone- 
shaped  opening,  with  its  apex  directed  inwards  and  somewhat 
forwards,  and  as  the  antrum  in  its  external  boundaries 


EXPLANATORY    NOTE    TO    PLATE    XXXI. 


This  plate  shows  the  partially  completed  Stacke-Schwartze  operation.  The  course 
of  the  facial  nerve  in  its  bony  canal  and  its  relations  to  the  tympanic  cavity  and  its 
contents  is  well  shown. 

i,  Facial  nerve;  2,  incus;  3,  stapes;  4,  the  remains  of  the  membrana  tympani, 
showing  the  handle  of  the  malleus  and  its  short  process ;  5,  the  remains  of  the  pos- 
terior osseous  canal  wall. 

300 


PLATE  XXXI 


The  Radical  Mastoid  Operation.  301 

usually  is  met  with  somewhat  inward  to  the  middle  of  the 
posterior  wall  of  the  bony  canal,  one  should  carefully  watch 
for  it  in  this  situation.  When  the  antrum  has  been  opened 
in  the  usual  manner,  the  next  step  is  to  remove  the  posterior 
canal  wall  with  chisel,  gouge  and  cutting  forceps.  The  bone 
is  best  removed  here  in  small  wedge-shaped  pieces  above  a 
line  corresponding  to  the  base  of  the  orifice  in  the  mastoid 
and  the  floor  of  the  aditus;  the  bridge  of  bone  formed  by 
the  posterior  wall,  in  other  words,  being  broken  down  to 
a  level  with  the  floor  of  the  osseous  auditory  canal,  for  about 
two-thirds  of  its  distance  inwards.  This  part  is  made  con- 
tinuous with  the  opening  in  the  mastoid  process  for  the  dis- 
tance previously  mentioned,  as  the  inner  third  cannot  be 
completely  removed  in  this  manner  on  account  of  the  danger 
to  the  facial  nerve.  When  the  opening  in  the  antrum  has 
been  made  a  bent  probe  or  Stacke's  protector  is  passed  into 
the  attic,  and  using  this  as  a  guide  and  guard  for  the  canal 
and  nerve,  the  wedge  of  bone  mentioned  is  thus  cut  away. 
Great  care  should  be  used  in  removing  the  inner  section  of 
the  posterior  meatal  wall,  and  after  this  has  been  done,  the 
tympanic  cavity  should  be  entered  by  the  removal  of  the 
external  attic  wall,  or  that  part  of  it  which  still  remains. 
This  may  be  done  with  a  narrow  chisel,  or  if  the  bone  be 
carious  in  part,  with  the  curette,  or  the  forceps  chisel  may  be 
employed.  The  projecting  or  overhanging  ledge  of  bone 
here  should  be  entirely  removed,  including  any  small  pro- 
jections or  recesses  in  the  bone,  until  the  parts  have  been 
made  smooth  and  the  surface  is  directly  continuous  with  the 
roof  of  the  tympanic  cavity.  The  osseous  tissue  here  should 
be  so  cut  away  that  when  the  probe  or  protector  is  used  it 
can  be  withdrawn  directly  outwards  on  a  plane  with  the 
superior  wall  of  the  external  canal,  without  encountering 
any  resistance.  Sometimes  a  few  spicules  of  bone  remain 
where  the  posterior  wall  has  been  removed  and  catch  the 


302  Suppuration  of  the  Middle  Ear. 

protector  as  it  is  being  withdrawn ;  these  should  be  removed 
with  the  chisel,  so  that  communication  between  the  various 
cavities  is  entirely  free.  The  thin  plate  of  bone  which  may 
now  remain  at  the  inner  end  of  the  posterior  canal  wall  is 
then  carefully  removed  in  the  same  manner,  so  that  if  there 
be  not  too  much  morbid  tissue  in  the  tympanum,  both  the 
oval  and  round  windows  may  be  seen.  As  this  small  area 
of  bone  lies  immediately  below  the  prominence  of  the  facial 
canal,  extreme  caution  must  be  used  in  removing  it,  but  with 
care  this  may  readily  be  done  without  damaging  the  nerve, 
and  as  it  forms  in  part  the  posterior  tympanic  space  where 
purulent  material  is  apt  to  be  retained,  it  should  not  be 
allowed  to  remain  (see  plate  XXXI).  All  that  now  remains 
of  this  part,  and  which  obscures  to  some  extent  the  hypotym- 
panic  space,  is  the  spur  of  bone  through  which  the  facial 
nerve  passes  in  this  part  of  its  course.  This  should  be  very 
cautiously  smoothed  down  by  removing  thin  layers  of  the 
bone  with  a  small  sTiarp  chisel,  and  at  the  same  time  having 
an  assistant  watch  the  patient  for  any  signs  of  irritation  of 
the  nerve,  while  the  chiseling  is  continued  until  the  sharp 
spur  of  bone  has  been  smoothed  away. 

If  the  ossicles  have  not  already  been  removed  or  de- 
stroyed during  the  suppurative  changes,  they  may  now  be 
readily  extracted,  although  it  is  sometimes  advisable  to 
remove  the  malleus,  incus  and  remains  of  the  tympanic  mem- 
brane through  the  canal  as  a  preliminary  step  of  this  opera- 
tion. The  advantages  of  doing  this  before  the  osseous  tissue 
has  been  somewhat  extensively  broken  down  are  that  the 
relations  of  the  parts  are  more  easily  recognized,  and  if  the 
ossicles  are  left  until  a  later  stage  of  the  procedure,  they  are 
apt  to  be  obscured  by  the  blood  which  drains  in  the  deeper 
part  of  the  wound,  and  their  extraction  may  be  somewhat 
difficult.  In  many  cases,  however,  this  question  will  not  be 
presented,  as  these  bonelets  have  previously  been  removed 


The  Radical  Mastoid  Operation.  303 

through  the  canal  in  an  endeavor  to  cure  the  tympanic  sup- 
puration.    Small,  straight  and  curved  curettes  are  now  used 
to  clean  the  tympanic  cavity,  aditus  and  antrum  of  granu- 
lation tissue,  cholesteatomatous  masses  and  carious  bone, 
every  portion  of  the  larger,  single  cavity  now  made  being 
thoroughly  cleansed  in  this  way  of  morbid  material.     In 
curetting  these  parts,  care  must  be  taken  that  too  much 
force  be  not  used  on  account  of  the  thinness  of  the  walls 
and  the  proximity  of  dangeous  parts.     It  should  be  borne 
in   mind   that   the   roof  of   the   aditus   forms   part   of   the 
floor  of  the  cranial  cavity,   supporting  the  temporal  lobe 
of  the  brain  and  its  internal  wall  is  in  close  relationship 
with  the  semicircular  canals.     Particular  attention  should 
be  paid  to  the  region  of  the  attic  and  after  all  diseased 
tissue  has  been  removed  from  this  part,  the  roof  of  the 
tympanum  should  be  carefully  examined  with  the  probe  to 
find  any  evidences  of  carious  bone  which  may  be  present. 
Attention  must  also  be  directed  to  the  anterior  and  inferior 
portions  of  the  tympanum,  as  there  are  very  apt  to  be  small 
areas  of  carious  bone  here  which  escape  observation  unless 
one  carefully  goes  over  these  parts  in  detail.     If  the  recess 
of  the  lower  floor  of  the  tympanic  cavity  is  situated  at  a 
lower  level  than  usual,  it  will  be  necessary,  in  order  to  thor- 
oughly remove  all  the  diseased  tissue  here,  to  cut  away  the 
external  wall  of  the  hypotympanic  space.     This  may  be 
readily  done  with  a  few  strokes  of  the  chisel,  but  unless  it 
seems  to  be  absolutely  essential  the  bone  should  be  left  intact, 
as  far  as  possible,  as,  if  it  be  removed,  it  seriously  interferes 
with  the  growth  of  the  epithelial  cells  from  the  canal  into 
the  tympanic  cavity,  which  to  a  great  extent  takes  place  here, 
and  as  a  result  of  the  mass  of  granulations  which  form  after 
the  small  portion  of  osseous  tissue  is  removed,  the  epidermi- 
zation  of  the  cavity  is  often  materially  delayed.     Usually, 
however,  the  floor  of  the  tympanum  can  be  thoroughly  cu- 


304  Suppuration  of  the  Middle  Ear. 

retted  without  removing  this  wall,  but  care  must  be  taken 
that  the  jugular  fossa,  which,  as  previously  indicated,  is  in 
close  relation  with  this  part,  is  not  harmed  by  rough  or 
careless  curetting. 

As  in  no  small  part  the  success  of  the  operation  depends 
upon  the  thoroughness  with  which  the  exenterated  cavities 
are  kept  from  further  infection,  it  is  necessary  that  the  ante- 
rior wall  of  the  cavum  tympani  receives  special  attention 
in  order  to  obviate  any  danger  of  contamination  by  way  of 
the  Eustachian  tube.  For  this  reason  the  tympanic  mouth 
of  the  tube  should  be  obliterated  as  completely  as  possible  by 
curetting  away  any  softened  bone  that  may  be  found,  a  very 
small  curette  being  necessary  to  get  well  into  the  mouth  of 
the  tube,  and  care  must  be  taken  in  removing  the  osseous 
tissue  on  account  of  the  close  relationship  of  the  tube  at  this 
point  with  the  internal  carotid  artery.  All  granulation  tissue 
must  be  removed,  both  in  and  around  the  opening  of  the  tube 
and  the  mucous  membrane  lining  its  orifice  should  be  entirely 
removed,  so  that  the  growth  of  healthy  granulation  tissue 
and  the  subsequent  cicatricial  contraction  will  entirely  oblit- 
erate it.  Should  this  not  be  accomplished,  a  redevelopment 
of  granulation  tissue  soon  takes  place  at  this  point,  and  if 
the  tube  thus  remains  patulous,  the  otorrhcea  will  often 
continue  as  the  result  of  infection  from  the  nasopharynx. 
After  this  has  been  accomplished  and  all  diseased  tissue  and 
carious  bone  has  been  removed  from  the  newly  formed  cav- 
ity, the  next  step  in  the  operation  is  the  removal  of  the 
mastoid  contents,  or  as  much  as  may  be  found  involved  in 
the  suppurative  process.  While  any  portion  of  the  temporal 
bone  may  be  involved  in  the  carious  changes  or  be  the  seat 
of  a  condensing  osteitis,  the  former  condition  associated  with 
necrosis  occurs  in  the  following  order  of  frequency,  accord- 
ing to  Schwartze,  and  the  gross  lesions  may  be  as  a  rule 
found  in  such  locations:  the  mastoid  process,  the  posterior 


The  Radical  Mastoid  Operation.  305 

and  upper  wall  of  the  external  auditory  canal,  the  roof  of 
the  tympanum,  the  ossicles,  the  inner  wall  of  the  tympanum, 
the  groove  of  the  lateral  sinus,  the  floor  of  the  tympanic 
cavity,  the  posterior  wall  of  the  carotid  canal,  the  labyrinth, 
and  finally  the  internal  auditory  meatus. 

The  extent  of  the  tissue  destruction  varies  in  practically 
every  case  operated  on,  Stacke  believing  that  the  caries  in 
chronic  suppurative  otitis  rarely  is  confined  alone  to  the 
ossicles,  and  yet  at  the  same  time  rarely  goes  beyond  the 
tympanic  cavity,  but  this  view  can  hardly  be  substantiated 
after  seeing  many  cases  of  chronic  otorrhcea,  as  it  is  not  at 
all  unusual  to  find  the  mastoid  process  extensively  disor- 
ganized, an  example  of  this  being  well  shown  in  a  Jcase  of 
Kirchner's,  where,  during  the  course  of  the  operation,  the 
entire  mastoid  process,  with  a  part  of  the  squamosa,  was 
removed  as  a  large  sequestrum.  In  practically  all  cases  of 
chronic  otorrhcea  which  undergo  the  radical  operation  for 
the  cure  of  the  suppuration,  granulation  tissue  and  carious 
bone  are  found  in  the  antrum  or  its  immediate  vicinity  and 
in  a  much  smaller  number  of  cases  the  dura  is  exposed  at 
various  points,  especially  by  the  removal  of  a  small  carious 
area  on  the  roof  of  the  antrum,  while  in  other  instances  the 
tissue  destruction  exposes  the  lateral  sinus.  The  extent 
of  the  morbid  changes  and  their  relation  to  and  association 
with  the  symptom  complex  being  well  shown  by  Jenkins  in 
a  study  of  these  points  in  eighty  consecutive  cases  where  the 
radical  operation  was  performed.  In  each  case,  in  addition 
to  the  discharge,  one  or  more  of  the  following  symptoms 
being  present:  pain  in  the  affected  ear  or  on  the  same  side 
of  the  head,  vertigo,  nausea,  vomiting  and  general  malaise. 
In  most  of  the  cases  there  were  polypi  or  granulation  tissue 
in  the  tympanum,  tenderness  over  the  mastoid  process,  swell- 
ing of  the  lining  of  the  external  auditory  canal,  bulging 
downward  of  the  posterior  wall  of  the  canal  and  the  adjacent 

21 


306  Suppuration  of  the  Middle  Ear. 

part  of  Shrapnell's  membrane,  facial  paralysis,  caries  of  the 
ossicles  or  the  presence  of  roughened  bone  found  by  the  probe 
in  the  walls  of  the  tympanic  cavity,  the  symptoms  and  phys- 
ical conditions  rarely  being  found  singly,  but  mostly  grouped 
together  in  varying  proportions. 

The  next  step  in  the  operation  is  the  removal  of  all  the 
diseased  tissue  in  the  mastoid,  the  extent  of  the  removal  of 
the  outer  layer  of  bone  for  this  purpose  varying  with  the 
extent  of  the  morbid  changes  which  are  found  in  the  par- 
ticular case.  If  this  is  not  extensive,  it  is  usually  desirable 
not  to  enlarge  the  opening  to  too  great  an  extent,  as  the 
smaller  the  area  in  the  mastoid  which  may  be  opened,  con- 
sistent with  the  thorough  removal  of  all  morbid  tissue,  the 
more  rapidly  will  the  parts  heal.  When  the  vertical  portion 
of  the  mastoid  is  involved  or  cholesteatoma  is  present,  the 
opening  should  be  extensive  and  should  be  enlarged  poste- 
riorly and  inferiorly,  and  the  bone  should  be  cautiously  re- 
moved above  if  this  becomes  necessary.  On  the  other  hand, 
when  the  cortex  is  carious  or  a  fistulous  opening  on  the  sur- 
face is  found,  the  one  should  be  removed  in  this  direction,  ir- 
respective of  the  location,  until  the  opening  embraces  all  the 
parts  which  may  be  involved.  The  principle  to  be  carried 
out  in  this  respect  being  that  all  the  surface  of  the  bone  over- 
lying the  cells  and  cavities,  should  be  entirely  removed  if 
diseased  tissue  lie  beneath,  so  that  all  parts  are  converted 
into  one  large  open  space,  so  that  when  a  bent  probe  is  laid 
against  the  inner  wall  of  the  tympanum,  aditus  or  antrum 
it  may  be  withdrawn  outwards  without  meeting  with  the 
least  obstruction.  The  amount  of  bone  which  must  be  re- 
moved from  the  mastoid  interior  by  means  of  the  curette, 
or  with  the  chisel  if  hard  bone  is  encountered  over  a  pneu- 
matic space  which  is  presumably  infected,  again  depends 
entirely  upon  the  amount  of  diseased  tissue  which  may  be 
found.  Although  the  mastoid  process  may  appear  not  to  be 


The  Radical  Mastoid  Operation.  307 

extensively  involved,  it  is  essential  to  obliterate  all  the  cavi- 
ties, including  the  cellular  structure  of  the  process  and  the 
cancellated  structure  of  the  tip.  All  prominences  or  ridges 
should  be  removed  so  that  the  walls  of  the  cavity  which  is 
formed  by  the  tympanum,  attic,  aditus,  antrum,  mastoid  and 
external  auditory  canal,  are  smooth  and  composed  of  hard 
healthy  tissue,  inspection  being  made  of  the  posterior  wall 
of  the  antrum  and  that  portion  in  relation  with  the  lateral 
sinus,  which  may,be  the  seat  of  a  small  focus  of  caries,  which 
should  be  eradicated  even  if  the  sinus  be  exposed.  If  the 
bone  has  not  already  been  removed  which  overhangs  the 
antrum,  this  should  now  be  done  by  again  placing  the  pro- 
tector over  the  facial  canal  and  stapedial  regions,  as  it  may 
be  necessary  to  protect  these  parts  and  the  inner  wall  of  the 
antrum,  and  with  the  chisel  the  external  edges  of  the  bone 
here  are  cut  away,  until  it  is  on  a  level  with  the  margin  of 
the  opening  in  the  mastoid.  The  parts  should  be  then  wiped 
dry  with  gauze,  all  bleeding  controlled  and  all  parts  of  the 
cavity  should  again  finally  be  examined  to  see  that  the  walls 
are  perfectly  smooth  and  no  rough  places  have  been  left  or 
depressions  or  projections  ignored.  If  any  places  are  found 
which  are  not  smooth,  even  though  composed  of  healthy  bone, 
these  must  be  properly  cared  for,  a  few  strokes  of  the  chisel 
usually  being  sufficient,  as  the  more  perfectly  the  walls  in 
their  entirety  are  made  as  smooth  as  possible,  the  more  uni- 
form will  be  the  resultant  granulating  surface  and  the  more 
rapid  will  healing  take  place  (see  plate  XXX). 

When  all  the  diseased  tissue  has  .been  removed  and  the 
walls  of  the  cavity  resulting  smoothed  down,  as  described, 
the  next  step  in  the  procedure  is  the  placing  of  the  membra- 
neous canal  walls  in  position  by  a  plastic  operation.  In 
either  of  the  so-called  radical  operations  described,  some 
method  must  be  adopted  to  form  an  epidermal  covering  for 
the  newly  formed  bone  surfaces  and  this  may  to  a  great 


308  Suppuration  of  the  Middle  Ear. 

extent  be  accomplished  by  splitting  the  membraneous  canal 
and  applying  the  flaps  thus  made  to  the  osseous  surfaces. 
Alderton  believes  that  it  is  wrong  to  turn  the  skin  flaps  for- 
ward from  the  posterior  part  of  the  external  cartilaginous 
canal  into  the  bone  wound,  as  the  folding  of  the  skin  he 
claims  makes  the  opening  from  the  bone  into  the  canal  smaller 
and  perichondritis,  and  chondritis  of  the  auricle  is  apt  to 
develop,  while  ceruminous  collections  are  apt  to  occur  from 
the  inclusion  of  these  glands  in  the  parts.  This  opinion,  how- 
ever, is  not  held  by  the  great  majority  of  otologists,  and  while 
he  believes  that  it  is  much  preferable  to  remove  entirely  the 
segment  of  the  soft  tissues  of  the  canal  wall  opposite  the 
bone  wound,  such  a  procedure  does  not  seem  advisable  where 
the  bone  wound  is  at  all  of  any  size.  The  flaps  should  be 
formed  from  the  fibro-cartilaginous  canal  and  in  part  from 
the  concha,  and  while  the  shape  of  the  flap  must  necessarily 
vary  in  different  cases  as  in  some  the  canal  flaps  are  sufficient 
to  fairly  well  cover  the  parts  desired,  in  others  it  will  be  nec- 
essary in  addition  to  this  to  utilize  a  portion  of  the  tissue 
from  the  concha,  in  order  to  thoroughly  form  a  covering  for 
the  parts.  A  satisfactory  method  of  performing  this  plastic 
operation  is  to  make  a  horizontal  incision  completely  through 
the  soft  tissues  of  the  membraneous  canal  at  its  posterior 
aspect  and  extending  from  where  it  has  been  cut  away  close 
to  the  annulus  tympanicus,  outwards  to  the  root  of  the 
auricle.  In  this  manner  two  triangular-like  flaps  are  formed 
from  which  the  cartilage  may  be  dissected  out  or  allowed 
to  remain,  as  may  be  desired,  although  if  this  is  done,  it  is 
possible  to  better  apply  the  flaps  with  more  accuracy  to  the 
surfaces  desired.  These  are  then  pressed  backwards  into 
the  bony  cavity  in  close  contact  with  its  walls  in  the  position 
desired  and  held  in  position  by  tampons  of  iodoform  gauze, 
or  in  order  to  obtain  a  more  secure  adhesion,  one  of  the 
flaps  should  be  sutured  to  the  periosteum  behind  and  above 


The  Radical  Mastoid  Operation.  309 

the  osseous  opening,  while  the  other  flap  is  sutured  to  the 
periosteal  tissues  below.  The  sutures  should  be  of  cat- 
gut and  in  order  that  they  may  withstand  a  considerable 
amount  of  tension  without  tearing  through  the  tissues,  they 
should  be  inserted  at  some  distance  from  the  cut  borders  of 
both  the  canal  flaps  and  the  periosteal  surface  and  should 
also  in  addition  be  passed  through  the  entire  thickness  of 
the  tissues  of  the  canal.  Should  the  cavity  in  the  bone  be 
such  that  the  flaps  formed  in  this  way  will  not  cover  the 
desired  space,  another  method  may  be  employed  with  con- 
siderable satisfaction  in  many  cases.  This  consists  in  making 
a  horizontal  incision  in  the  membraneous  canal  along  the  pos- 
tero-superior  wall  and  extending  the  same  length  as  the 
incision  described  in  the  previous  method,  parallel  with  the 
axis  of  the  canal.  Close  to  the  concha  and  at  right  angles 
to  it  another  incision  is  made  downwards  and  backwards,  so 
that  rectangular  flaps  are  formed  instead  of  those  of  the 
triangular  shape  mentioned,  these  being  placed  over  the  bone 
surface  and  treated  in  the  same  manner  as  previously  de- 
scribed. Other  methods  of  performing  the  plastic  operation 
may  also  be  employed,  as  will  be  described  in  another  chapter. 
In  both  cutting  out  the  flaps  from  the  canal  and  in  their 
application  to  the  walls  of  the  bony  cavity,  care  should  be 
taken  in  the  former  instance  that  the  cartilage  of  the  auricle 
should  not  be  subjected  to  too  great  an  amount  of  traumatism, 
or  that  the  incisions  should  not  be  made  too  freely  into  it, 
as  if  this  should  occur,  perichondritis  is  liable  to  ensue,  with 
subsequent  deformity  of  the  pinna.  Also,  in  applying  the 
flaps  to  the  osseous  walls,  care  must  be  exercised  that  too 
much  prominence  be  not  given  to  the  posterior  wall  of  the 
canal,  for  should  this  be  done,  the  auricle,  after  healing  has 
taken  place,  will  not  correspond  in  position  with  that  of  the 
opposite  ear,  and  as  a  result  of  the  large  cavity  behind  the 
position  of  the  membraneous  canal,  considerable  deformity 


310  Suppuration  of  the  Middle  Ear. 

will  ultimately  ensue.  This  can  be  prevented,  however,  by 
carefully  placing  the  flaps  and  retaining  them  in  position, 
and  if  necessary  by  cutting  away  with  the  chisel  a  small 
portion  of  the  superior  edge  of  the  meatus.  Should  the  bone 
cavity  be  very  large,  the  flaps  from  the  canal  will  not  always 
be  sufficient  to  cover  the  parts  and  a  long  time  will  be  neces- 
sary in  the  epidermization  of  the  wound,  but  when  the  cavity 
is  small  no  advantages  are  to  be  derived  from  additional 
methods  of  hastening  this  process,  although  under  the  former 
circumstances  the  application  of  skin  grafts  by  the  method  of 
Thiersch  is  of  great  practical  value.  The  grafting  may  be 
performed  as  the  next  step  in  the  operation  after  the  canal 
flaps  have  been  sutured  in  position,  or  some  prefer  to  delay 
this  until  the  walls  of  the  cavity  are  covered  with  a  fair 
amount  of  healthy  granulation  tissue;  the  method  of  graft-' 
ing  as  one  of  the  concluding  steps  of  the  radical  operation 
will  here  be  considered,  while  that  performed  later  will  best 
be  described  in  the  chapter  on  the  after  treatment  of  the 
mastoid  operation.  As  the  technique  of  this  procedure,  as 
described  by  Dench,  has  proven  most  successful,  it  is  here 
given  in  detail  as  employed  by  this  author :  "The  grafts  used 
are  taken  from  the  thigh  and  at  the  time  the  patient  is  pre- 
pared for  the  mastoid  operation,  the  anterior  and  internal 
surfaces  of  the  thigh  are  scrubbed  with  soap  and  water,  then 
shaved,  again  scrubbed  with  a  I  to  1000  bichloride  solu- 
tion and  washed  with  equal  parts  of  alcohol  and  ether.  Anti- 
septic dressings  are  then  applied,  being  kept  in  place  by 
adhesive  straps,  a  layer  of  cotton  and  a  firm  bandage.  When 
the  operation  has  proceeded  to  the  time  for  employing  the 
grafts,  the  dressings  from  the  leg  are  removed,  large  grafts 
are  cut  and  if  possible  from  one  and  a  half  to  two  and  a  half 
inches  in  length.  These  are  removed  from  the  razor  to  a 
large  spatula  with  a  sharp  needle  and  a  few  drops  of  normal 
saline  solution  is  dropped  on  the  epidermis  and  the  spatula 


The  Radical  Mastoid  Operation.  311 

is  also  moistened  before  slipping  the  grafts  on  it.  Several 
should  be  cut  so  that  if  one  fails  to  place  the  first  in  posi- 
tion others  will  be  ready.  The  auricle  is  then  drawn  for- 
ward and  a  sponge  is  placed  along  the  cut  margin  of  the 
anterior  flap  to  prevent  oozing  into  the  bony  cavity  while  the 
graft  is  being  introduced ;  the  posterior  margin  of  the  incision 
may  also  be  protected  in  the  same  way,  although  this  is  less 
apt  to  bleed.  The  temporary  packing  to  control  the  bleed- 
ing is  then  withdrawn  from  the  cavity  and  the  spatula,  car- 
rying a  large  graft,  is  taken  in  the  left  hand  and  carried  com- 
pletely across  the  bony  cavity,  so  that  the  free  margin  of  the 
spatula  rests  close  to  the  anterior  wall  of  the  meatus.  With 
the  sharp  needle  the  edge  of  the  graft  is  then  pushed  off  the 
spatula  and  held  against  the  anterior  wall  of  the  meatus, 
the  spatula  gradually  being  drawn  backwards  so  that  the 
graft  falls  into  the  bony  cavity.  This  should  be  done  some- 
what rapidly  so  that  the  graft  may  sink  deeply  into  the  bony 
cavity  before  the  deeper  parts  become  filled  with  blood.  The 
graft  is  then  applied  closely  to  the  internal  wall  of  the  tym- 
panum, to  the  tympanic  roof,  the  prominence  of  the  Fallopian 
canal,  the  horizontal  semicircular  canal,  and  should  partially 
line  the  mastoid  antrum.  It  is  then  held  in  place  with  small 
pledgets  of  cotton  impregnated  with  aristol  and  these  are 
applied  by  carrying  the  first  pledget  downwards,  forwards 
and  inwards  to  force  a  portion  of  the  graft  well  into  the 
mouth  of  the  Eustachian  tube.  The  parts  are  now  plugged 
as  rapidly  as  possible  to  hold  the  graft  in  position,  and  as  its 
edges  always  roll  more  or  less  after  the  deeper  pledgets  are 
placed,  the  graft  should  be  spread  out  more  perfectly  with 
a  long  sharp  needle,  so  as  to  line  the  more  superficial  parts 
of  the  cavity,  the  entire  space  occupied  by  the  graft  being 
filled  with  the  little  pledgets.  Should  the  graft  fold  upon 
itself  when  packing  it  into  position,  so  that  it  will  not  spread 
out  completely  over  the  walls  of  the  cavity,  then  a  second 


312  Suppuration  of  the  Middle  Ear. 

graft  should  be  used  to  complete  the  lining,  as  it  makes  no 
difference  if  the  grafts  overlap  or  if  the  second  graft  par- 
tially overlaps  the  cotton  packing,  for  as  long  as  it  is  brought 
into  contact  with  the  bone  walls,  the  overlapping  part  or 
the  part  not  applied  to  the  walls,  sloughs,  while  the  remain- 
der becomes  attached.  By  carrying  out  this  method  all  the 
exposed  walls  of  the  cavity  may  be  covered  and  the  healing 
of  the  parts  will  be  greatly  facilitated,  while  if  the  diseased 
tissue  has  previously  been  thoroughly  removed,  the  purulent 
discharge  will  rapidly  cease.  In  cases  where  the  skin  graft- 
ing is  thus  made,  a  strip  of  sterile  gauze  is  placed  on  top  of 
the  cotton  pledgets,  with  the  end  brought  out  by  way  of  the 
enlarged  meatus  and  the  mastoid  wound  may  be  closed  in  the 
usual  manner." 

In  those  cases  where  skin  transplantation  is  not  per- 
formed and  the  operative  procedure  has  resulted  in  the  re- 
moval of  but  a  moderate  amount  of  tissue,  the  parts  should  be 
cleansed  with  an  antiseptic  solution,  such  as  a  I  to  5000  or 
even  stronger  bichloride  solution,  or  they  may  be  carefully 
wiped  out  instead  with  gauze  sponges  and  then  may  be  dusted 
with  an  antiseptic  powder  or  not  as  may  seem  best.  In  such 
cases  as  these  the  incision  behind  the  ear  may  be  entirely 
closed  by  interrupted  sutures  of  silk  or  silkworm  gut,  so  as 
to  obtain  perfect  apposition  and  a  rubber  drainage  tube  is 
inserted  into  the  canal  so  that  it  goes  well  into  the  tympanic 
cavity  and  drainage  by  way  of  the  meatus  is  obtained.  Some- 
times when  the  posterior  wound  is  primarily  sutured,  one 
may  allow  the  anterior  flap  to  slightly  overlap  the  posterior, 
as  this  is  supposed  to  result  in  a  less  conspicuous  cicatrix 
and  prevents  the  ear  becoming  depressed  in  the  enlarged 
canal  or  from  turning  too  much  outwards,  while  to  prevent 
a  deformity  of  the  meatus  which  may  occasionally  follow  the 
displacement  of  the  outer  segment  of  the  canal,  the  drainage 
tube  used  should  be  of  sufficient  size  to  fit  snugly  in  the  canal. 


The  Radical  Mastoid  Operation.  313 

In  however  those  cases  where  the  operation  has  been 
very  extensive  it  appears  advisable  that  the  posterior  wound 
should  remain  open  at  first  and  then  later  it  may  be  allowed 
to  close  by  granulation  or  kept  free  by  a  retro-auricular 
opening  as  may  be  desired,  the  latter  being  especially  in- 
dicated in  the  presence  of  cholesteatoma.  In  cleansing 
the  wound  previous  to  packing  irrigations  may  be  used  if 
the  purulent  discharge  has  been  thin  and  irritating,  or  choles- 
teatomatous  masses  have  been  found  in  considerable  quan- 
tity, as  in  such  cases  it  is  practically  impossible  to  render 
the  parts  at  all  clean  without  such  irrigations,  but  in  the 
majority  of  cases  and  in  all  in  which  the  dura  or  sinus  has 
been  exposed,  irrigation  is  not  necessary,  as  the  cavity  can 
be  thoroughly  cleansed  by  wiping  it  out  with  gauze  sponges. 
The  upper  angle  of  the  wound  may  then  be  brought  together 
with  two  or  three  fine  silk  sutures,  either  just  before  or  after 
the  packing  has  been  applied,  and  if  done  before,  the  cavity 
is  thoroughly  dried  with  gauze  pads  and  an  antiseptic  powder 
may  be  dusted  over  the  parts.  The  tympanum,  antrum, 
meatus  and  all  parts  of  the  mastoid  cavity  are  then  packed 
with  small  pieces  of  iodoform  gauze  and  the  cavity  filled  with 
gauze  strips,  so  that  drainage  may  be  obtained  both  by  way 
of  the  meatus  and  the  post-auricular  opening.  The  packing 
should  be  quite  firmly  placed  in  position,  but  care  must  be 
exercised  that  it  does  not  exert  too  much  pressure  over  the 
region  of  the  stapes,  as  if  this  is  done,  unpleasant  symptoms 
may  develop,  as  in  a  case  reported  by  Herzog,  where  the 
pressure  of  two  firm  iodoform  tampons  in  the  cavity  of  the 
middle  ear  was  followed  by  pseudo-epileptic  attacks.  Over 
these  dressings  the  usual  dressings,  consisting  of  a  pad  of 
gauze  and  a  layer  of  cotton  held  in  place  by  a  suitable  band- 
age, as  described  in  a  previous  chapter,  is  placed.  In  order 
to  obviate  to  a  great  extent  the  pain  from  which  the  patient 
suffers  at  the  first  change  of  dressings  Whiting  suggests  that 


Suppuration  of  the  Middle  Ear. 

a  piece  of  Cargile's  membrane  or  thin  rubber  tissue  perfor- 
ated with  small  holes  be  closely  approximated  to  the  walls 
of  the  bony  cavity  and  over  this  the  gauze  dressing  is  applied, 
so  that  the  gauze  is  kept  away  from  direct  contact  with  the 
bone,  and  thus  the  pain  consequent  to  its  removal  is  obviated. 
In  the  performance  of  the  radical  operation,  the  facial 
nerve  and  external  semicircular  canal  assume  a  serious  im- 
portance on  account  of  their  position  in  the  midst  of  the  oper- 
ative field  and  the  consequent  danger  to  which  they  are 
invariably  exposed.  It  is  therefore  desired,  in  addition  to 
what  has  previously  been  said,  to  further  add  here  a  few 
more  facts  throwing  light  upon  the  dangers  which  exist  and 
their  avoidance  in  operations  upon  this  region.  In  the  re- 
moval of  large  masses  of  bone,  the  facial  nerve  is  especially 
liable  to  be  wounded  during  its  course  through  the  cavum 
tympani  when  the  osseous  tissue  is  being  taken  away  to  ex- 
pose the  inner  wall,  the  danger  of  traumatism  at  this  point 
not  being  of  any  moment  until  a  communication  has  been 
made  with  the  tympanic  space.  After  the  opening  in  the 
mastoid  has  been  made  and  the  posterior  canal  wall  is  to 
be  removed,  the  protector  or  a  probe  bent  at  right  angles 
should  be  passed  through  the  external  auditory  canal  and 
held  by  an  assistant  in  the  posterior  part  of  the  epitympanic 
space,  when  the  osseous  tissue  should  be  carefully  removed, 
as  previously  outlined,  until  the  protector  becomes  visible. 
In  this  way  one  has  a  guide  to  the  exact  location  of  the  nerve, 
but  as  a  still  further  protection,  only  the  portion  of  the  pos- 
terior wall  directly  in  front  of  the  mastoid  opening  should  at 
first  be  cut  away,  and  if  this  be  done  so  that  the  opening 
thus  made  leads  directly  into  the  tympanum  by  the  gradual 
removal  of  the  bony  wall  there  will  be  practically  no  danger 
of  wounding  the  nerve  by  this  procedure,  especially  if  the 
compact  bone  mass  forming  the  inner  extremity  of  this  wall 
is  not  interfered  with  to  any  extent.  Jones,  in  thirty  cases, 


EXPLANATORY   NOTE    TO    PLATE    XXXII. 


This  plate  shows  the  completed  Stacke-Schwartze  operation,  with  an  exposure  of 
the  sigmoid  sinus  and  the  dura  of  the  middle  cerebral  fossa. 
i,  Sigmoid  sinus;  2,  middle  cerebral  fossa. 

316 


PLATE  XXXII 


The  Radical  Mastoid  Operation.  317 

had  permanent  facial  paralysis  following  in  two  and  it  was 
also  transient  in  the  same  number,  while  he  states  that  in 
order  to  avoid  injuring  the  nerve,  the  operator  must  see  well 
into  the  cavity  in  the  bone.  It  may  also  be  noted  in  this 
connection,  that  the  development  of  facial  paralysis  after 
operation  is  not  always  necessarily  due  to  injury  of  the  nerve, 
as  in  a  case  reported  by  Mahn,  the  paralysis  occurred  a  few 
hours  after  operation ;  the  patient,  however,  was  subsequently 
accidentally  killed  and  the  autopsy  showed  that  the  paralysis 
was  the  result  of  an  independent  neuritis,  as  the  nerve  pre- 
sented neither  a  solution  of  its  continuity,  nor  an  apparent 
wound.  If  it  be  possible  only  to  remove  the  lateral  walls 
of  the  antrum,  the  nerve  will  rarely  be  injured  here  and  the 
same  avoidance  of  injury  may  be  obtained  by  cutting  away 
the  posterior  canal  wall  no  lower  than  the  middle  of  the 
margin  of  the  tympanum.  It  should  also  be  remembered 
that  too  tight  packing  may  injure  the  nerve,  and  that  this 
may  also  take  place  as  the  result  of  carelessness  in  using  the 
protector,  especially  if  any  weight  be  exercised  on  its  handle. 
In  removing  the  post-meatal  wall  which  is  the  most  dan- 
gerous part  of  the  radical  operation  as  regards  the  Fallopian 
canal,  Schwartze  says  that  the  blows  of  the  mallet  on  the 
chisel  should  be  careful  and  gentle,  and  not  at  a  right  angle 
but  at  an  acute  angle  to  the  posterior  wall,  and  the  chisel 
should  cut  instead  of  prying  out  pieces  of  bone,  while  the 
beveled  edge  of  the  chisel  should  be  so  turned  that  its  ten- 
dency would  be  to  get  shallower,  rather  than  deeper.  At 
the  same  time,  as  a  matter  of  great  importance,  the  bent  or 
olive-pointed  probe  should  be  used  at  frequent  intervals  to 
carefully  explore  the  parts  which  are  being  chiseled  away. 
As  a  still  further  source  of  injury  to  the  nerve  may  be  the 
curette,  for  if  this  be  used  too  forcibly  or  roughly,  especially 
at  the  bend  of  the  aditus  or  along  the  floor  here,  it  may  pene- 
trate too  deeply  an  area  of  carious  bone  and  seriously  damage 


318  Suppuration  of  the  Middle  Ear. 

the  nerve;  this  can  readily  be  avoided,  however,  by  the  em- 
ployment of  gentleness  and  care  in  the  use  of  this  instrument 
and  the  free  exposure  of  the  operative  field. 

What  has  been  stated  in  regard  to  the  facial  nerve  here 
is  also  equally  applicable  to  the  external  semicircular  canal, 
but  with  care  this  organ  may  readily  be  avoided,  as  it  is 
situated  immediately  above  the  Fallopian  canal  and  the  open- 
ing in  the  bone  must  be  unnecessarily  high  to  injure  it,  and 
as  a  rule  it  can  readily  be  recognized  on  the  red  coloration 
of  the  antral  wall  as  a  yellowish  prominence.  The  exposure 
of  the  meninges  or  lateral  sinus  (see  plate  XXXII)  during 
the  course  of  an  operation  for  chronic  otorrhcea  has  been 
fully  described  in  a  previous  chapter,  but  it  may  be  further 
noted,  that  when  the  former  is  accidentally  exposed  one 
should  avoid  as  far  as  possible  the  further  employment  of 
the  curette  or  chisel  in  that  particular  place,  for  fear  that  the 
purulent  secretion  may  drain  between  the  dura  and  the  adja- 
cent temporal  bone  and  the  area  exposed  should  also  be 
packed  off  from  the  general  cavity  in  the  bone  by  a  separate 
piece  of  gauze,  so  that  the  possibilities  of  infection  are  more 
effectually  guarded  against.  The  same  should  be  done  when 
the  lateral  sinus  is  involuntarily  opened,  but  if  the  hemor- 
rhage be  profuse,  it  may  become  necessary  to  tightly  pack 
the  bone  cavity  with  iodoform  gauze  and  postpone  the  termi- 
nation of  the  operation  to  a  later  date  until  the  walls  of  the 
sinus  have  healed. 

When  a  well-defined  cholesteatoma  is  found  on  operation, 
or  there  is  an  excessive  amount  of  cholesteatomatous  tissue 
distributed  through  the  cellular  system  of  the  bone,  it  will 
be  necessary  to  somewhat  modify  the  radical  operation,  espe- 
cially as  regards  the  handling  of  the  walls  of  the  osseous 
cavity.  Should  the  membrane  which  lines  the  cavity  con- 
taining the  cholesteatomatous  mass  be  thoroughly  cleansed 
of  this  material,  no  recurrence  should  take  place,  but  expe- 


The  Radical  Mastoid  Operation.  319 

rience  has  shown  that  it  is  practically  impossible  to  achieve 
this  end  and  leave  the  membrane  in  place,  as  recurrence  of 
the  peculiar  epithelial  proliferation  results  within  a  compara- 
tively short  time.  Although  Grant  believes  that  when  the 
radical  operation  for  cholesteatorna  is  done,  and  a  large 
cavity  is  found  lined  with  a  homogeneous  membrane,  one 
may  leave  the  membrane  in  situ  and  simply  scrape  out  the 
contents  and  sterilize  the  lining  with  alcohol.  In  several 
cases  he  found  that  this  procedure  was  followed  by  speedy 
subsidence  of  the  discharge  and  satisfactory  after  results. 
In  some  cases,  and  probably  the  majority  in  which  this  mem- 
brane appears  to  be  smooth,  it  will  be  found  on  close  exami- 
nation that  it  is  pierced  with  numerous  minute  openings 
which  communicate  with  small  channels  in  the  bone  which 
are  filled  with  the  proliferating  epithelium,  so  that  it  can  be 
readily  understood  that  irrespective  as  to  how  thoroughly  the 
lining  membrane  itself  may  be  removed,  these  channels  in 
the  bone  cannot  be  obliterated  by  simple  measures,  so  that 
in  addition  to  the  absolute  removal  of  this  membrane,  it  is 
also  essential  that  the  layer  of  osseous  tissue  beneath  this, 
which  contains  the  epithelial  elements,  must  also  be  destroyed. 
Stacke,  in  order  to  accomplish  this,  after  removing  every- 
thing that  presents  the  least  evidence  of  pathological  change, 
grinds  down  the  bone  with  the  electromotor  burr,  so  that 
the  epithelial  masses  in  the  Haversian  canal  system  are  oblit- 
erated, while  for  the  same  purpose,  the  procedure  recom- 
mended by  Zaufal  may  be  satisfactorily  employed  of  thor- 
oughly curetting  the  bone  surfaces  and  then  following  this 
by  the  application  of  Paquelin's  cautery,  or  painting  the 
osseous  walls  with  tincture  of  cantharides.  Unless  the  pro- 
liferative  power  of  the  cholesteatorna  membrane  is  entirely 
prevented  by  some  of  the  measures  here  recommended,  it 
will  be  difficult  to  obtain  a  healthy  granulation  surface  for 
the  bone  cavity,  and  what  is  still  more  important,  any  por- 


320  Suppuration  of  the  Middle  Ear. 

tion  of  it  which  may  still  remain  acts  as  a  matrix  for  the 
production  of  a  further  recurrence.  Should  these  measures 
then  fail  to  prevent  its  redevelopment,  the  osseous  cavity 
should  be  carefully  watched  during  the  after  treatment  and 
every  trace  of  excessive  epithelial  development  should  be 
radically  eradicated  with  the  curette.  In  those  cases  where 
this  tissue  has  been  so  thoroughly  removed  at  the  time  of 
the  radical  operation  that  recurrence  need  not  be  considered, 
the  post-auricular  opening,  as  will  be  described  later,  may  be 
allowed  to  close  by  granulation,  but  where  there  is  any  uncer- 
tainty in  regard  to  its  recurrence,  a  permanent  opening 
should  be  maintained  posteriorly,  so  that  the  least  evidence 
of  recurrence  may  be  seen  and  immediately  eradicated. 

As  in  the  simple  mastoid  opening,  the  electromotor  burr 
has  been  employed  to  some  extent  in  evacuating  the  bone  in 
the  radical  operation,  while  as  an  aid  in  reducing  irregu- 
larities of  the  walls  of  the  osseous  cavity,  smoothing  off  pro- 
jecting bone  surfaces,  and  especially  in  grinding  down  the 
bony  walls  when  cholesteatoma  has  been  removed,  it  is  of 
great  value.  Experience  has  shown  to  a  great  extent  that 
it  is  not  advisable  to  employ  the  burr  in  the  tympanum,  but 
elsewhere  its  employment  is  comparatively  safe,  and  it  is 
especially  advantageous  in  leveling  down  the  facial  spur, 
as  the  slightest  irritation  of  the  nerve  becomes  immediately 
evident,  so  that  the  facial  muscles  at  once  contract,  and  with 
a  minimum  amount  of  precaution,  severe  injury  to  the  nerve 
is  very  improbable.  Barkan  believes  that  the  mallet  and 
chisel  will  ultimately  be  given  up  for  the  burr  in  performing 
the  mastoid  operation,  and  as  being  superior  to  the  former 
for  this  purpose,  he  states  that  when  we  come  down  too  near 
the  extremity  of  the  bony  wedge,  where  the  Fallopian  canal 
and  horizontal  semicircular  canal  lie  in  close  proximity,  he 
found  that  the  insertion  of  an  ordinary  strabismus  hook  be- 
tween the  bony  wedge  and  the  neighboring  wall  of  the  tym- 


The  Radical  Mastoid  Operation.  321 

panic  cavity  affords  a  perfect  protection  against  accidental 
injury  of  either  the  facial  or  semicircular  canals,  the  hook 
being  pressed  forward  and  the  burr  being  made  to  work 
against  it.  In  the  use  of  the  burr  in  the  bone  cavity,  either 
for  removing  large  masses  of  carious  bone  or  reducing  irreg- 
ularities, care  should  be  taken  that  from  time  to  time  it  be 
allowed  to  cool,  for  if  this  is  not  done  the  heat  generated 
in  destroying  the  osseous  tissue  may  be  sufficient  to  produce 
considerable  damage,  as  in  several  recorded  cases  its  employ- 
ment has  resulted  in  necrosis  of  the  walls  of  the  osseous 
cavity  from  the  reduction  of  the  vitality  of  the  tissue  by  the 
excessive  heat  generated  in  its  rapid  rotation. 


22 


CHAPTER  V. 

MODIFICATIONS  OF  MASTOID 
OPERATIONS. 


323 


MODIFICATIONS  OF  MASTOID  OPERATIONS. 

The  radical  mastoid  operation,  when  performed  to  re- 
move the  morbid  tissue  causing  the  discharge  and  associated 
symptoms  in  chronic  suppurative  otitis  media,  is  of  necessity 
modified  to  some  extent  in  adaptation  to  the  particular  fea- 
tures present  in  almost  every  case,  but  whether  any  step  of 
the  operative  procedure  deviates  from  the  methods  usually 
employed,  the  principle  aimed  at  must  always  remain  the 
same,  the  object  of  the  various  methods  employed  being  to 
convert  the  antrum,  epitympanic  space  and  tympanum  proper 
into  one  open  single  cavity  instead  of  a  series  of  partially 
closed  ones,  and  to  also  bring  these  into  direct  relation  and 
as  a  part  of  the  external  auditory  canal  or  the  eviscerated 
mastoid  process.  The  finished  procedure,  as  far  as  the  cut- 
ting away  of  the  osseous  tissue  is  concerned,  more  nearly 
approaches  the  surgical  ideal,  being  the  one  in  which  all  the 
diseased  tissue  is  removed  without  damage  to  the  highly 
important  structures  in  relation  with  the  affected  parts  and 
these  latter  cavities  being  thrown  into  a  single  space  with 
smooth  healthy  walls. 

When  the  suppurative  middle  ear  disease  has  been 

325 


326  Suppuration  of  the  Middle  Ear. 

neglected  and  a  fistula  of  the  mastoid  process  has  developed, 
either  at  its  most  common  site  on  the  cortex  near  the  center, 
or  above,  in  close  relation  with  the  opening  of  the  meatus, 
modifications  in  the  operative  procedure  may  be  necessary, 
as  stated  by  Politzer,  as  the  fistula  usually  leads  into  a  large 
cavity  filled  with  pus  and  granulation  tissue,  or  often  with 
cholesteatomata  and  sequestrated  fragments  of  bone.  In 
such  cases  the  initial  incision  should  be  made  over  the  fistula, 
and  it  is  often  only  necessary  to  chisel  away  a  thin  bony  shell 
to  expose  the  middle  ear,  as  the  postero-superior  wall  of  the 
canal  and  part  of  the  external  attic  wall  are  generally  de- 
stroyed. When  this  condition  is  found  all  that  is  usually 
required  is  to  remove  the  granulations  and  cholesteatoma- 
tous  masses,  the  remains  of  the  osseous  meatal  wall  and 
attic,  with  the  projecting  bony  ridges,  and  scrape  out  and 
smooth  off  the  walls  of  the  cavity. 

In  very  rare  instances  the  sclerotic  changes  of  the  mas- 
toid process  may  be  so  great  that  it  is  impossible  to  perform 
the  Stacke-Schwartze  or  any  operation  which  contemplates 
opening  the  antrum  through  the  mastoid  on  account  of  the 
excessive  projection  forward  of  the  lateral  sinus.  This 
abnormality  has  been  previously  mentioned,  but  when  it  is 
found  to  be  present,  even  a  large  cavity  in  the  bone  cannot 
be  made  with  the  ordinary  Stacke  method  and  it  becomes 
necessary  to  continuously  chisel  the  bone  away  by  means  of 
a  very  small  chisel  through  the  external  auditory  canal  into 
the  attic  and  aditus,  as  it  will  be  found  in  such  cases  that  but 
little  remains  of  the  antrum  as  it  has  become  greatly  reduced 
in  size.  Fortunately,  in  such  individuals  the  amount  of 
carious  bone  is  very  small  and  nearly  always  limited  to  the 
immediate  region  of  the  cavum  tympani,  so  that  in  cutting 
the  bone  away  in  a  backward  direction  to  reach  the  antrum, 
which  should  be  found  and  opened,  however  small  it  may 
be,  one  is  not  necessarily  exposing  the  patient  to  great 


Modifications  of  Mastoid  Operations.         327 

danger,  especially  if  the  protector  is  passed  through  the  ex- 
ternal canal  and  is  used  as  a  guide  in  the  ordinary  manner 
after  the  epitympanic  space  has  been  freely  laid  open. 

Jackson  has  pointed  out  that  the  hearing  power  has  been 
much  better  where  the  posterior  wound  has  been  allowed  to 
heal  from  the  bottom  with  the  removal  of  the  posterior  canal 
wall  in  the  usual  manner,  but  not  incising  the  membraneous 
canal  and  thus  avoiding  the  resultant  deformity  of  the 
concha,  sometimes  necessary  to  obtain  an  adequate  meatal 
opening  of  sufficient  size  for  the  after  treatment,  as  made 
in  the  usual  Stacke-Schwartze  operation,  with  the  Koerner 
or  Panse  flaps.  Where  both  ears  are  affected  and  the  ques- 
tion of  audition  assumes  a  much  more  serious  aspect,  he 
advises  against  these  operative  procedures  and  favors  the 
healing  of  the  posterior  wound  from  the  bottom  whenever 
possible,  on  account  of  this  method  more  safely  conserving 
the  hearing.  In  the  operation  upon  the  single  ear,  which 
is  usually  the  case,  and  where  the  hearing  in  the  other  ear 
is  normal  or  of  fair  efficiency,  one  should  be  careful  in  trans- 
planting skin  to  cover  the  bone  defect  that  it  is  not  placed 
too  thickly  over  the  region  of  the  oval  or  round  windows 
on  account  of  the  impairment  of  hearing  which  may  some- 
times ensue.  In  epidermic  transplantation  to  overcome  cho- 
lesteatomatous  formation,  Bezold  claims  that  when  this  is 
used  in  the  bone  cavities  it  reduced  the  period  of  healing 
to  weeks  instead  of  months,  as  the  skin  flaps  thus  trans- 
planted line  the  previously  suppurating  cavities  with  a  dry 
membrane  instead  of  a  moist  secreting  surface,  and  the 
necessity  of  a  permanent  opening  behind  the  auricle  is  abol- 
ished. It  must  be  remembered,  however,  that  credible  ob- 
servers have  found  that  the  epithelial  proliferation  may  occur 
in  the  skin  in  which  the  aural  cavities  have  been  lined,  so 
that  under  all  conditions  this  in  itself  is  not  an  absolute  guar- 
antee that  the  cholesteatoma  will  be  permanently  inhibited. 


328  Suppuration  of  the  Middle  Ear. 

As  regards  the  method  of  removing  the  osseous  tissue  in 
performing  the  radical  operation  for  chronic  tympanic  sup- 
puration, the  Zaufal  method  is  often  compared  with  that  of 
the  Stacke-Schwartze,  and  for  all  practical  purposes  as 
regards  its  technique  is  similar  to  it,  these  two  terms  being 
used  quite  often  interchangeably  in  describing  the  radical 
operation.  Zaufal,  however,  removes  the  mastoid  cortex 
and  the  postero-superior  wall  of  the  osseous  auditory  canal 
and  then  enters  the  antrum,  after  which  the  external  attic 
wall  is  removed  and  the  epitympanic  space  exposed.  The 
similarity  between  this  and  the  usual  radical  operation  is 
therefore  very  close,  the  modification  only  consisting  in  the 
removal  of  the  postero-superior  wall  of  the  canal  at  the  same 
time  as  the  mastoid  cortex  is  cut  away,  instead  of  directly 
entering  the  antrum  at  first  through  the  mastoid  process  and 
then  as  a  later  step  cutting  away  the  canal  wall,  the  technique 
of  the  operation  in  both  instances  being  otherwise  the  same, 
and  as  it  has  previously  been  described,  will  require  no 
further  repetition  here. 

The  Zauf  al-Kuster  method  of  opening  the  antrum  through 
the  mastoid  process  as  the  primary  procedure  differs  in  no 
essential  from  the  method  here  described,  excepting  that  a 
mastoid  bone  flap  may  be  formed  to  close  the  posterior  open- 
ing as  in  the  Kuster  operation,  which  will  later  be  mentioned. 

The  Panse  modification,  when  employed  in  the  presence 
of  cholesteatoma,  does  not  concern  the  removal  of  the  osseous 
tissue  in  any  way  differing  from  the  complete  radical  opera- 
tion, but  is  essentially  concerned  in  the  method  of  making 
the  flaps  for  lining  the  exposed  bony  cavities  from  the  mem- 
braneous canal,  which  will  be  described  in  detail  in  the  suc- 
ceeding chapter,  the  object  of  this  flap  method  being  such 
that  through  the  large  meatal  opening  the  bony  cavity  can 
be  thoroughly  examined  in  every  part  and  the  presence  of 
any  redevelopment  of  the  cholesteatoma  may  be  immediately 
determined  and  properly  treated. 


Modifications  of  Mastoid  Operations.         329 

Biehl,  in  order  to  save  as  far  as  possible  the  tympanic 
contents,  in  cases  of  radical  operation  where  the  suppura- 
tion is  confined  to  a  greater  or  lesser  extent  to  the  attic,  with 
the  presence  of  a  perforation  in  Shrapnell's  membrane,  as 
a  first  step  of  his  operation  opens  the  aditus  by  removing 
its  lateral  wall.  After  this  has  been  done  and  the  extent 
of  the  diseased  process  has  been  ascertained,  the  usual  radical 
operation  may  be  carried  out  if  the  condition  of  the  parts 
warrants  it,  or  in  the  cases,  as  here  described,  in  which  this 
modification  is  applicable,  all  or  part  of  the  outer  wall  of 
the  attic  or  antrum,  or  both,  may  be  removed  as  required 
in  the  particular  case,  the  value  of  this  procedure  being 
mainly  in  the  fact  that  it  protects  the  facial  nerve  from  any 
damage  and  allows  of  the  complete  exploration  of  the  attic 
in  front  and  of  the  antrum  behind,  and  thus  decides  how 
far  operation  on  these  parts  may  be  necessary.  As  in  a  not 
inconsiderable  number  of  cases  it  is  not  absolutely  necessary 
to  remove  the  membrana  tympani  and  ossicular  chain  by  this 
method,  it  is  sometimes  possible,  as  claimed  by  its  author, 
to  remove  the  purulent  nidus  from  the  aditus  and  antrum, 
and  the  attic  and  ossicles  are  thus  restored  to  their  normal 
condition  as  far  as  the  presence  of  suppuration  may  be 
concerned. 

The  modification  of  the  radical  operation  of  whatever 
nature,  in  which  the  diseased  tissue  is  removed  by  enlarging 
the  external  auditory  canal  from  within  the  canal  backwards 
instead  of  from  the  mastoid  process  forwards,  irrespective 
of  the  particular  method  employed  to  accomplish  this,  to 
a  great  extent  in  many  cases  possesses  considerable  advan- 
tage over  what  has  been  called  the  double  channel  operation, 
inasmuch  as  the  after  treatment  is  carried  on  through  two 
openings,  one  being  the  meatus,  the  other  the  posterior  open- 
ing in  the  soft  tissues  and  bone.  The  single  channel  opera- 
tion, when  such  is  practicable,  obviates  this,  and  as  shown 


330  Suppuration  of  the  Middle  Ear. 

by  Love,  the  former  possesses  certain  disadvantages,  as  the 
patient  must  wear  an  external  dressing  for  a  number  of 
months  to  cover  the  mastoid  wound ;  when  it  is  determined  to 
close  this  wound  there  is  great  doubt  as  to  the  conduct  of  the 
inner  end  of  the  mastoid  cavity  as  to  whether  it  will  become 
an  undrained  sinus  or  pocket  in  which  pus  will  collect  and 
produce  considerable  trouble  in  the  future,  thus  defeating  the 
object  for  which  the  operation  was  performed,  as  it  is  cer- 
tain in  quite  a  number  of  cases  that  the  purulent  discharge 
continues  even  after  the  most  careful  treatment.  Although 
healing  does  take  place  after  a  longer  or  shorter  period, 
there  is  often  an  unsightly  depression  remaining  behind  the 
auricle,  while  the  surest  result  is  obtained  by  keeping  the 
mastoid  wound  perfectly  open  until  all  discharge  from  the 
middle  ear  has  ceased  and  to  then  close  it  by  a  plastic  opera- 
tion. In  contradistinction  to  these  disadvantages  of  the 
double  channel  operation,  the  single  channel  method,  as 
shown  by  this  author,  offers  the  advantages  that  all  dressings 
may  be  removed  from  the  side  of  the  head  within  two  weeks 
and  the  patient  may  again  resume  his  usual  occupation  at 
that  time.  All  the  after  treatment  is  carried  out  by  way  of 
the  widened  canal,  which  should  be  so  large  that  every  part 
of  the  healing  surface  can  be  seen  through  the  speculum  and 
every  nook  or  corner  of  the  space  can  be  thoroughly  cleansed 
and  treated  as  may  be  indicated,  while  another  great  advan- 
tage is  that  complete  healing  takes  place  as  a  rule  by  the  third 
month  after  operation. 

Gelle's  modification  of  the  mastoid  operation  concerns 
itself  only  with  the  avoidance  of  danger  to  the  facial  nerve 
and  the  horizontal  semicircular  canal,  by  cutting  away  the 
osseous  tissue  in  their  neighborhood  by  means  of  a  specially 
constructed  saw  instead  of  the  usual  method  of  the  chisel. 
The  usual  opening  of  the  antrum  is  first  performed  through 
the  mastoid  process,  and  after  the  antrum  has  been  fully 


Modifications  of  Mastoid  Operations.         331 

exposed,  a  wire  is  introduced  through  this  cavity  forwards 
into  the  tympanum  and  out  through  the  external  auditory 
canal.  This  wire  is  employed  only  to  carry  the  saw  to  its 
position  within  the  cavities  and  when  it  has  been  placed  in 
situ  the  remaining  bridge  of  bone  is  cut  away  by  it.  A 
chain  saw  is  used,  the  links  being  very  short,  so  that  the 
instrument  may  readily  be  drawn  from  the  antrum  through 
the  exposed  tympanic  cavity  and  two  cuts  are  made  by  it; 
the  first  from  above  downwards,  which  should  be  directed 
towards  the  apex,  while  the  second  incision  is  to  be  made 
in  a  horizontal  direction,  so  that  in  this  way  the  bony  wall 
is  removed  by  cutting  away  the  deeper  parts  from  within 
outwards,  while,  as  the  cuts  are  made  external  to  and  below 
the  parts  which  it  is  necessary  to  avoid,  no  danger  can  occur 
in  this  particular  region. 

Bergmann's  operation,  which  is  one  of  the  most  impor- 
tant modifications  of  the  radical  procedure,  is  characterized 
by  the  removal  of  the  inferior  lamella  of  the  superior  wall 
of  the  external  osseous  auditory  canal  and  in  connection  with 
the  external  attic  wall  this  part  is  cut  away  before  the  re- 
moval of  the  posterior  osseous  canal  wall,  which  is  later 
destroyed  and  the  antrum  then  opened.  This  operation  is 
especially  indicated  in  those  cases  of  chronic  suppuration 
where  the  attic  and  pneumatic  spaces  of  the  mastoid  process 
bear  the  brunt  of  the  morbid  changes  and  in  which  drainage 
by  way  of  the  lower  tympanum  and  canal  is  not  sufficient-, 
the  removal  of  the  carious  bone  with  the  granulation  tissue 
and  purulent  material  being  thoroughly  accomplished  by 
this  procedure.  The  basis  of  this  operation  depends  upon 
the  anatomical  development  of  the  squamous  portion  of  the 
temporal  bone  in  relation  with  the  cavum  tympani,  as  the 
bone  here  is  divided  into  two  well-defined  lamellae,  of  which 
the  internal  comprises  a  part  of  the  roof  of  the  tympanic 
cavity,  while  the  second  lamella  closes  the  opening  between 


332  Suppuration  of  the  Middle  Ear. 

the  extremities  of  the  tympanic  ring  in  an  inward  and  down- 
ward direction,  so  that  when  fully  developed  the  ring  is 
closed  by  this  curved  segment  in  this  manner.  As  the  growth 
of  the  squamous  plate  continues  during  early  life,  it  so  pro- 
jects that  the  roof  of  the  external  canal,  of  which  it  forms  a 
part,  extends  externally  in  a  plane  that  is  nearly  horizontal, 
so  that  in  the  young  child,  where  it  forms  an  arch-like  struc- 
ture at  this  point,  becomes  changed  in  later  adult  life,  and 
here  forms  the  horizontal  osseous  lamella  spoken  of.  As 
shown  by  Bergmann,  the  outer  attic  wall  is  placed  at  an 
angle  formed  by  the  divergence  of  these  internal  and  external 
plates  of  the  squamous  process,  and  if  an  opening  be  made 
parallel  to  the  roof  of  the  canal  between  these  two  osseous 
plates,  it  will  enter  the  epitympanic  space.  To  accomplish 
this  the  usual  incision  is  made  over  the  mastoid  close  to  the 
insertion  of  the  auricle  and  the  membraneous  canal  is  sepa- 
rated from  the  osseous  canal  walls  as  before  described,  so 
that  the  superior  margin  of  the  bony  canal  is  thoroughly  ex- 
posed. The  upper  wall  of  the  canal  and  the  osseous  tissue 
beneath  it,  which  is  mainly  diploic  in  character,  is  then  cut 
away  with  the  chisel  until  the  epitympanic  space  has  been 
exposed,  the  lines  of  the  bone  removed  following  the  superior 
wall  of  the  canal  in  an  inward  direction.  As  this  part  of 
the  tympanum  contains  the  articulation  of  the  malleus  and 
incus  and  is  by  far  the  most  frequent  seat  of  pathological 
change,  especially  of  a  carious  process,  it  is  thus  directly 
exposed  by  the  removal  of  the  osseous  tissue  in  this  manner. 
The  ossicles  or  their  remains  are  thus  extracted  through  this 
opening  in  the  bone  and  the  tegmen  tympani  is  curetted  and 
carefully  exposed  for  carious  bone  which  should  be  removed 
if  found  here,  while  should  the  extent  of  the  pathological 
process  be  such  that  the  antrum  and  mastoid  cells  are  then 
found  to  be  involved,  they  may  be  readily  opened  and  cleaned 
out  by  enlarging  the  opening  already  made  in  the  bone  in 


Modifications  of  Mastoid  Operations.         333 

a  posterior  direction.  After  all  the  diseased  tissue  has  thus 
been  eliminated,  the  postero-superior  wall  of  the  mem- 
braneous canal  may  be  then  divided  and  the  soft  tissue  flaps 
thus  obtained  are  pressed  backwards  over  the  bony  cavity 
which  has  been  formed,  so  that  the  entire  system  of  cavities 
and  cell  spaces  of  the  region  are  thrown  into  one  common 
cavity  in  relation  with  the  tympanic  space  and  the  parts  can 
then  be  treated  by  way  of  the  enlarged  external  canal,  or 
any  carious  areas  which  may  subsequently  develop  can  be 
eliminated  in  this  manner  instead  of  reopening  the  mastoid 
process,  as  in  some  other  forms  of  operative  procedure.  As 
a  method  of  removing  carious  tissue  and  obtaining  free 
drainage  from  the  deeper  portions  of  the  involved  temporal 
bone,  this  procedure,  either  alone,  or  preferably  in  connec- 
tion with  Stacke's  operation,  possesses  many  features  of 
value,  especially  in  those  cases  where  for  various  reasons 
it  is  considered  inadvisable  to  enter  the  antrum  through  the 
mastoid  process,  while  in  the  small  class  of  cases  where  the 
lateral  sinus  is  placed  so  far  anteriorly  that  the  antrum  can- 
not be  entered  except  by  way  of  the  canal,  it  may  be  employed 
with  considerable  satisfaction,  the  gauze  drainage  and  ex- 
ternal dressings  being  the  same  in  this  operation  as  in  the 
usual  Stacke  procedure  and  the  after  treatment  is  also  carried 
out  along  the  same  lines. 

The  Ballance  operation  for  chronic  suppurative  otitis,  is, 
according  to  Gibson,  the  most  radical  of  all  complete  mastoid 
operations,  but  it  is  attended  with  less  disfigurement  and  is 
followed  by  quicker  healing  of  the  bone  cavity  than  any 
other  operation  of  so  radical  a  nature,  the  chief  features 
of  this  operation  being  that  the  skin  incision,  though  quite 
long,  is  in  the  line  of  the  hair  and  becomes  practically  invis- 
ible after  the  complete  healing  of  the  parts,  the  mouth  of 
the  meatus  is  enlarged  without  disfigurement,  while  the  pos- 
terior wall  of  the  cartilaginous  meatus  with  the  posterior 


334  Suppuration  of  the  Middle  Ear. 

wall  of  the  concha  is  displaced  upwards  and  backwards  and 
so  fixed  as  to  form  the  outer  and  part  of  the  superior  wall 
of  the  posterior  portion  of  the  enlarged  meatus.  Gibson 
further  stating  as  an  important  modification,  that  in  from 
ten  to  twenty-one  days  after  this  portion  of  the  operation 
the  essential  parts  of  the  granulating  walls  of  the  enlarged 
bone  cavity  are  covered  with  Thiersch  grafts  which,  if  suc- 
cessful, lead  to  the  rapid  healing  of  the  whole  cavity  and 
its  being  lined  by  a  thin  layer  of  epithelium.  Ballance  states 
that  in  order  to  obtain  a  successful  outcome  of  a  mastoid 
operation  it  is  requisite  to  obtain  the  fulfilment  of  two  con- 
ditions, the  complete  removal  of  all  diseased  tissue,  and  sec- 
ondly, the  healing  of  the  large  bone  wound  which  this  neces- 
sitates from  the  bottom.  In  order  to  avoid  the  pain  conse- 
quent upon  the  frequent  tamponing  of  the  cavity  and  to 
shorten  the  long  time  before  cicatrization  is  complete  in  the 
usual  radical  operation  and  to  ensure  the  thoroughness  of 
the  epidermization  of  the  bone  cavity,  he  modifies  the  opera- 
tion by  carrying  out  two  separate  procedures,  the  first  being 
the  operation  for  the  removal  of  all  the  diseased  tissue,  and 
the  second  procedure  which  follows  at  a  later  period  the 
operation  for  healing  the  wound.  In  performing  the  first 
of  these  two  operations,  the  usual  incision  is  made  behind 
the  auricle  which  is  held  well  forward  with  the  retrac- 
tor. The  bone  opening  is  then  made  with  the  electromotor 
burr  or  gouge  and  the  posterior  wall  of  the  bony  meatus  is 
removed  with  rongeur  forceps;  the  entire  outer  wall  of  the 
attic  should  also  be  removed,  so  that  the  external  auditory 
canal,  tympanum,  attic,  antrum  and  as  much  of  the  mastoid 
as  is  necessary  is  converted  into  one  large  bone  cavity.  The 
operation  should  be  done  under  brilliant  illumination  and  all 
parts  should  be  thoroughly  curetted  with  sharp  spoons  until 
the  osseous  walls  of  the  cavity  are  left  clean  and  hard,  care 
being  taken  in  curetting  the  posterior  part  of  the  inner  wall 


Modifications  of  Mastoid  Operations.         335 

of  the  tympanum  on  account  of  the  danger  to  the  overhang- 
ing Fallopian  canal  here,  as  the  fossa  of  the  aqueduct  fre- 
quently contains  granulations  and  may  be  carious,  while  in 
removing  the  bone  the  Stacke  protector  should  be  employed 
to  shield  the  facial  nerve  and  external  semicircular  canal 
as  in  the  usual  operation.  An  incision  is  then  made  into  the 
inferior  wall  of  the  cartilaginous  canal,  throughout  its  entire 
length  and  carried  well  into  the  concha,  where  it  is  pro- 
longed with  a  curve  upwards  and  backwards  as  far  as  the 
level  of  the  anterior  commencement  of  the  helix.  The  thick 
layer  of  tissue  behind  the  meatus  is  then  removed  and  its 
posterior  wall  forming  this  part  of  the  meatal  flap  is  pushed 
upwards  and  backwards  and  attached  to  the  mastoid  flap  by 
silkworm  gut  sutures.  The  osseous  cavity  is  then  thoroughly 
cleansed  and  packed  with  narrow  strips  of  gauze,  of  which 
the  end  should  be  brought  out  through  the  meatus,  while  the 
incision  over  the  mastoid  process  should  be  completely  closed 
with  fine  silkworm  gut  or  horse  hair  sutures.  If  there  is 
much  discharge  from  the  ear,  the  packing  in  the  bone  cavity 
may  have  to  be  changed  within  a  few  days,  but  if  the  cavity 
has  been  thoroughly  cleansed  it  can  usually  remain  un- 
changed until  the  time  for  the  second  operation. 

The  second  step  of  the  operation  consists  in  the  appli- 
cation of  skin  grafts  to  the  osseous  cavity  when  it  has  become 
lined  with  delicate  pink  granulation  tissue,  which  usually 
takes  place  in  from  seven  to  ten  days,  but  may  take  from  two 
to  three  weeks.  The  patient  is  anaesthetized,  the  original 
incision  over  the  mastoid  process  is  opened  with  the  handle 
of  the  knife  and  the  auricle  is  displaced  well  forwards.  All 
oozing  or  active  bleeding  from  the  edges  of  the  wound  or 
granulating  surface  is  then  controlled  after  the  gauze  pack- 
ing has  been  removed  and  large  epithelial  grafts  taken  from 
the  thigh  or  arm,  or  preferably  a  single  graft  is  made  to 
cover  and  lie  flat  against  every  part  of  the  walls  of  the 


336  Suppuration  of  the  Middle  Ear. 

cavity  if  such  be  possible.  In  applying  the  graft  it  is  essen- 
tial that  the  following  parts  be  thoroughly  protected  by  it: 
the  anterior  wall  of  the  cavity  formed  internally  by  the  ante- 
rior boundary  of  the  tympanum  and  attic  and  externally  by 
the  anterior  wall  of  the  large  osseous  meatus,  the  anterior 
part  of  the  cavity  formed  by  the  tegmen  tympani  and  the 
superior  wall  of  the  enlarged  osseous  meatus,  the  inner  wall 
of  the  attic  and  tympanum,  the  roof  of  the  antrum,  the  ridge 
formed  by  the  facial  canal,  and  the  inner  wall  of  the  antrum. 
If  more  than  one  graft  is  used,  care  should  be  taken  to  avoid 
overlapping  on  the  one  hand  and  the  leaving  of  uncovered 
granulation  tissue  on  the  other,  while  drops  of  blood  or 
bubbles  of  air  caught  between  the  graft  and  the  bony  wall 
should  be  avoided  as  much  as  possible,  as  they  are  apt  to 
produce  considerable  trouble.  This  is  best  overcome  by 
placing  the  graft  edgewise  over  the  depth  of  the  cavity  in- 
stead of  pushing  it  directly  by  its  central  portion  into  the 
tympanum.  Tiny  moist  pledgets  of  gauze  and  steel  probes 
with  pear-shaped  heads  measuring  from  four  to  six  milli- 
meters in  diameter  are  used  in  accurately  applying  the  graft 
to  the  raw  bone  surface,  so  that  when  the  grafting  is  com- 
pleted all  eminences  and  depressions  should  be  as  clear  to 
the  eye  of  the  operator  as  before  the  operation.  The  best 
protective  for  the  grafts  is  pure  gold  leaf  about  one  or  two 
one-thousandths  of  an  inch  in  thickness,  which  is  carefully 
pushed  into  position  so  that  all  eminences  and  depressions  in 
the  bone  are  clearly  denned.  After  this  has  been  carefully 
placed,  a  narrow  strip  of  dry  iodoform  gauze  is  packed  into 
the  tympanum,  attic  and  antrum  and  the  end  is  brought  out 
through  the  meatus.  The  mastoid  incision  is  then  com- 
pletely closed  and  the  usual  outside  dressings  are  applied. 
One  week  later  the  packing  is  removed,  which  procedure  is 
absolutely  painless,  but  the  gold  leaf  is  allowed  to  remain 
for  a  longer  period.  Three  or  four  days  later  this  should 


Modifications  of  Mastoid  Operations.         337 

be  gently  removed  with  forceps  after  irrigation  and  the  irreg- 
ular cavity  will  be  seen  to  be  pure  white  in  color,  when  a 
small  amount  of  dry  gauze  is  packed  against  the  grafts  and 
this  is  changed  every  two  or  three  days  until  healing  is  com- 
plete. Milligan  advises  as  an  improvement  in  this  proced- 
ure, in  order  to  avoid  the  constant  oozing  at  the  grafting 
operation,  that  the  original  incision  over  the  mastoid  be 
opened  two  days  previous  to  placing  the  grafts,  while  he  also 
suggests  in  order  to  avoid  some  of  the  difficulties  in  manipu- 
lating the  grafts  that  they  be  floated  into  position  by  filling 
the  cavity  with  a  warm  saline  solution,  which  may  afterwards 
be  withdrawn  by  means  of  a  pipette. 

While  for  some  time  previous  to  the  publication  of 
Kuster's  original  method  of  entering  the  tympanum,  the 
removal  of  the  posterior  wall  of  the  osseous  external  canal 
had  been  recommended,  this  operator  at  a  later  period  more 
clearly  defined  the  necessity  for  such  a  procedure  in  certain 
cases  of  chronic  suppurative  otitis  media.  He  carries  the 
opening  directly  into  the  tympanum  and  this  cavity  with  the 
antrum  is  curetted  as  may  be  required,  the  main  object  of 
this  operation  being  to  thus  remove  the  posterior  wall  of  the 
canal  in  order  to  expose  the  middle  ear  cavities,  and  he  bases 
the  rationale  of  this  procedure  upon  the  general  surgical 
principle  that  when  a  collection  of  pus  is  confined  within  a 
bony  cavity,  the  focus  of  infection  should  be  freely  opened 
in  order  that  the  morbid  changes  present  can  be  seen  and 
the  pathological  tissue  thoroughly  eradicated.  Kuster's 
more  recent  modification  of  the  radical  operation  concerns 
itself  directly  with  the  method  of  opening  the  mastoid  process 
and  is  known  as  the  osteo-plastic  method.  The  method  of 
forming  the  osteo-plastic  flap  consists  in  drawing  the  auricle 
well  forward  and  making  an  incision  close  along  its  posterior 
attachment,  beginning  slightly  above  the  level  of  the  external 
opening  of  the  auditory  canal.  The  incision  is  then  carried 

23 


338  Suppuration  of  the  Middle  Ear. 

downward  around  the  tip  of  the  mastoid  process  and  is  then 
continued  upward  along  its  posterior  border  to  the  same  level 
as  its  beginning.  This  forms  a  U-shaped  incision  which 
should  be  made  through  the  periosteum  to  the  bone,  the 
periosteal  layer  and  soft  tissues  then  being  pushed  aside  with 
the  elevator  and  with  a  broad  chisel  a  shallow  groove  is  cut 
into  the  bone  following  the  entire  outline  of  the  usual  incis- 
ion. Beginning  at  the  bottom  of  this  channel  in  the  bone, 
a  thin  osseous  flap  or  plate  is  then  split  off,  which  is  adherent 
to  the  soft  tissues  and  the  entire  skin-periosteum-bone  flap 
is  turned  upwards,  leaving  the  field  of  operation  free. 
After  the  diseased  tissue  of  the  mastoid  and  the  cells  in  con- 
nection with  it  have  been  removed  in  the  usual  manner,  the 
flap  in  its  entirety  is  replaced,  but  in  order  to  accomplish 
this  in  a  satisfactory  manner  it  may  be  necessary  to  cut  off 
a  small  piece  of  the  bone  from  its  lower  end,  so  that  a  small 
drain  may  be  led  from  the  cavity  formed  inside  the  bone  to  the 
surface.  The  author  claims  for  this  method  that  it  presents 
little  difficulty  in  its  performance,  rapid  healing  takes  place, 
and  in  case  the  sinus  or  dura  have  been  injured,  it  affords 
a  good  opportunity  to  apply  the  tampon.  Experience  has 
shown,  however,  that  such  is  not  the  case,  and  as  has  been 
noted  by  other  observers,  his  claim  in  regard  to  the  flap 
being  of  advantage  in  injuries  of  the  meninges  or  lateral 
sinus  is  not  worthy  of  consideration,  while  the  method  offers 
no  advantages  at  all  over  the  usual  operations,  but  possesses 
a  rather  doubtful  value. 

Relative  to  the  making  of  the  skin  flaps,  various  modi- 
fications have  been  devised  by  different  operators,  some  of 
more  or  less  value,  while  others  are  of  less  importance,  and 
are  only  applicable  in  a  limited  number  of  cases.  Of  the 
modifications  which  have  proven  of  service  in  some  cases, 
Lake  proposes  in  Stackers  operation  to  pave  the  floor  of  the 
artificial  opening  between  the  external  ear  and  the  antrum 


Modifications  of  Mastoid  Operations.         339 

with  the  dermal  lining  of  the  external  auditory  canal  only, 
the  cartilage  being  dissected  off  at  the  time  of  the  operation. 
While  the  same  author,  after  the  radical  operation,  believes 
that  the  posterior  meatal  flap  should  be  entirely  removed, 
because  after  it  has  been  turned  back  to  line  the  roof  of  the 
large  cavity  made  in  the  osseous  structures,  the  ceruminous 
glands  in  the  flap  continue  to  functionate  and  the  cerumen 
which  is  thus  produced  is  unable  to  escape  and  acts  as  a  for- 
eign body,  causing  considerable  annoyance.  In  such  cases 
where  the  ceruminous  glands  are  very  prominent  over  this 
portion  of  the  canal  wall,  it  will  be  advisable  to  remove  the 
tissue,  as  advised  by  Lake.  Dench  recommends  a  method  of 
forming  these  flaps  from  the  canal  wall  by  continuing  the 
usual  horizontal  incision  along  the  posterior  medial  wall  of 
the  cartilaginous  canal,  outwards  to  about  the  middle  of  the 
concha  and  from  the  conchal  extremity  of  the  horizontal 
incision,  another  incision  is  made  in  a  vertical  direction 
upwards  and  another  in  the  same  manner  downwards.  By 
dividing  the  tissues  in  this  way,  two  quadrilateral  flaps 
are  formed  and  then  the  conchal  cartilage  in  each  flap  is 
dissected  out  and  the  tissues  are  folded  backwards  upon 
themselves,  so  that  the  lower  flap  is  drawn  downwards, 
while  the  other  flap  is  placed  upwards,  and  both  are  stitched 
into  position  with  fine  gut  sutures,  so  that  the  opposing 
raw  surfaces  are  brought  into  apposition.  If  it  is  seen 
that  these  sutures  are  not  sufficient,  it  may  be  necessary 
in  some  cases  to  place  deep  retention  sutures  of  stronger 
gut.  A  better  method  of  forming  the  flaps  described  by 
the  same  operator,  is  to  incise  the  meatus  in  the  direc- 
tion of  its  long  diameter  along  the  line  of  its  posterior 
aspect  well  out  into  the  concha.  From  the  point  where  it 
enters  the  concha,  the  incision  is  curved  upwards  parallel 
to  the  antihelix  and  a  short  distance  in  front  of  this  point 
to  immediately  below  the  anterior  crus  of  the  antihelix.  In 


340  Suppuration  of  the  Middle  Ear. 

this  manner  a  large  flap  is  formed,  consisting  of  the  posterior 
and  upper  walls  of  the  fibrous  auditory  meatus  and  a  tongue- 
shaped  conchal  flap.  The  dermal  layer  of  the  concha  is 
raised  up  and  dissected  off  from  the  cartilage  of  the  flap 
and  the  cartilage  is  grasped  with  forceps,  dissected  away 
from  its  posterior  attachments  and  excised.  The  meatal  flap 
is  then  turned  backwards  upon  itself  and  stitched  in  position 
with  interrupted  sutures  of  fine  catgut,  while  the  tongue- 
shaped  flap  is  turned  backwards  and  upwards  through  the 
large  meatal  opening  formed  by  the  cutting  away  of  this 
flap  and  is  stitched  in  position  to  the  raw  surface  posterior 
to  it  by  fine  catgut  sutures. 

Randall,  in  performing  the  radical  operation,  advises  the 
omission  of  a  permanent  opening  behind  the  ear  as  being 
the  only  positive  cure  for  the  chronic  suppuration,  and  he 
further  believes  that  the  mastoid  cells  are  not  to  be  included 
in  the  operative  removal  of  the  parts  unless  they  are  demon- 
strably  affected.  He  obtains  epidermization  of  the  cavity, 
which  has  been  cleansed  out,  without  even  a  temporary  retro- 
auricular  opening  and  the  mastoid  wound  is  healed  by  first 
intention  after  it  has  been  closed  with  silver  wire  sutures. 
In  making  the  skin  flaps,  the  posterior  flap  from  the  fibrous 
canal  is  split  into  two  layers,  one  being  composed  of  skin, 
the  other  of  periosteum;  the  cartilage  is  then  removed,  so 
that  a  large  pliable  flap  is  obtained  which  readily  adopts  itself 
to  the  purpose  for  which  it  is  designed.  The  flaps  are  held 
in  place  by  means  of  gauze  pledgets  through  the  meatus, 
but  they  are  also  fastened  originally  in  position  through  the 
wound  behind  the  auricle,  after  which  the  latter  is  perma- 
nently closed  and  the  subsequent  dressings  and  after  treat- 
ment are  carried  out  through  the  external  auditory  meatus. 

As  a  method  of  filling  in  the  opening  behind  the  ear  after 
the  radical  operation  for  chronic  suppurative  otitis  media, 
the  procedure  adopted  by  Waring  may  be  useful  in  a  few 


Modifications  of  Mastoid  Operations.         341 

cases.  He  makes  a  free  opening  in  the  mastoid  and  after 
thoroughly  curetting,  fills  the  entire  space  with  long,  thin 
strips  of  cartilage  and  bone  taken  from  the  femur  and  tibia 
of  a  young  kitten,  which  is  killed  during  the  course  of  the 
mastoid  operation.  The  posterior  wound  is  then  closed  with 
sutures  and  the  external  auditory  canal  is  packed  with  a  strip 
of  gauze.  In  one  case  of  cholesteatoma  in  which  this  pro- 
cedure was  carried  out  there  was  no  indication  of  its  return 
after  two  years,  while  in  another  case,  where  the  large  cavity 
was  irrigated  for  several  weeks,  rendered  sterile  and  then 
filled  with  the  cartilage  and  bone  strips,  cure  resulted  and 
the  cavity  became  completely  filled,  and  in  another  case, 
owing  to  the  difficulty  in  making  the  cavity  aseptic,  the  bone 
grafts  did  not  take  and  the  Ballance  grafting  operation  was 
then  successfully  performed. 


CHAPTER  VI. 

THE  RETRO-AURICULAR  OPENING  AND 
PLASTIC  METHODS. 


343 


THE  RETRO-AURICULAR  OPENING  AND  PLASTIC  METHODS. 

While  various  modifications  of  the  usual  methods  of 
making  flaps  from  the  membraneous  canal  walls  in  order  to 
cover  the  exposed  bone  surfaces  and  hasten  epidermization 
after  the  radical  operation  for  chronic  suppurative  otitis  me- 
dia have  been  discussed  in  the  previous  chapters,  it  is  desired 
here  to  more  thoroughly  take  these  methods  into  considera- 
tion, especially  in  relation  to  the  permanent  retro-auricular 
opening  and  to  describe  the  methods  that  are  usually  em- 
ployed for  this  purpose.  Two  main  objects  are  to  be  attained 
by  the  employment  of  plastic  flap  methods  after  the  osseous 
tissue  of  this  region  has  been  extensively  removed  for  chronic 
tympanic  suppuration,  the  first  being  to  obtain  a  complete 
epidermic  covering  for  the  walls  of  the  cavity,  as  from  the 
epithelium  of  the  surface  of  the  flap,  proliferation  takes  place, 
and  if  the  underlying  granulating  surfaces  be  healthy,  they 
become  covered  with  a  dry,  nonsecreting  layer  of  protecting 
epithelial  tissue.  While  the  second  object  which  is  equally 
important  as  regards  drainage  and  the  hearing  ability  of 
the  individual,  is  the  prevention  of  stenosis  or  actual  stricture 
of  the  canal  from  the  inflammatory  thickening  or  subsequent 

345 


346  Suppuration  of  the  Middle  Ear. 

contraction  which  takes  place  at  the  point  where  the  mem- 
braneous tube  has  been  necessarily  divided  in  performing  the 
radical  operation. 

After  the  removal  of  all  the  diseased  tissue,  the  ultimate 
cessation  of  the  purulent  discharge  is  dependent  upon  the 
complete  epidermization  of  the  cavity  surgically  made  in  the 
bone,  and  in  order  to  accomplish  this  desirable  and  neces- 
sary issue,  the  essential  epithelial  cells  must  be  obtained  from 
the  anterior  and  inferior  canal  walls  which  have  been  allowed 
to  remain  in  their  natural  position,  from  the  flaps  made  from 
a  portion  of  the  membraneous  canal,  and  if  this  is  not  suffi- 
cient, from  transplantation  by  means  of  Thiersch  grafts. 
In  the  first  instance,  the  epithelium  commences  to  grow  from 
the  canal  into  the  tympanum,  as  described  in  the  epidermi- 
zation of  the  cavum  tympani  after  operation  via  the  external 
auditory  canal,  but  the  time  required  for  the  epithelium  thus 
produced  to  cover  the  walls  of  a  somewhat  extensive  cavity 
it  so  indefinite  that  even  when  the  plastic  flaps  are  also  em- 
ployed, skin  grafting  may  be  used,  especially  in  the  deeper 
parts  of  the  tympanic  cavity  and  antrum  which  the  flaps  will 
not  cover,  to  diminish  the  time  necessary  for  epidermization 
and  increase  the  rapidity  of  the  healing  process,  the  grafts 
being  applied  in  the  manner  previously  described,  either  at 
the  time  of  operation  or  at  a  later  period  when  the  osseous 
surfaces  have  become  covered  with  a  layer  of  granulation 
tissue.  One  frequently  finds  from  time  to  time  minute  areas 
of  epithelial  development  on  the  inner  walls  of  the  cavity, 
completely  isolated  from  similar  groups  of  cells;  these  are 
produced  from  small  patches  of  mucous  membrane  left  after 
curetting,  and  in  time  they  take  on  the  characteristics  of  a 
nonsecreting  cicatricial  membrane.  As  a  rule,  however,  such 
islets  of  tissue  are  of  but  little  value  in  effecting  the  desired 
epithelial  transformation,  although  they  are  undoubtedly  of 
service  in  aiding  the  growth  of  the  transplanted  epithelium 


Retro-Auricular  Opening  and  Plastic  Methods.   347 

which  may  be  applied  in  their  vicinity.  Should  the  latter  fail 
to  "take,"  one  should  look  for  evidences  of  defective  aseptic 
precautions  or  the  presence  of  further  carious  changes  in  the 
osseous  walls,  but  in  a  certain  small  proportion  of  cases, 
where  the  grafting  has  been  carefully  performed  and  where 
the  condition  of  the  parts  is  healthy,  the  grafts,  after  grow- 
ing for  a  time,  cease  to  remain  in  normal  condition  and 
become  destroyed  or  devitalized  to  a  greater  or  lesser  extent. 
The  choice  of  the  method  to  be  employed  in  making  the 
flaps  from  the  membraneous  canal  varies  to  a  great  extent 
with  the  amount  of  osseous  tissue  to  be  covered  in  the  indi- 
vidual case,  the  desires  of  the  operator,  and  the  post-aural 
conditions,  some  methods  being  inapplicable  when  the  in- 
cision over  the  mastoid  process  is  closed  at  once  to  obtain 
healing  by  first  intention,  others  being  of  service  only  when 
the  post-auricular  opening  is  to  remain  permanently,  or  when 
it  is  to  be  allowed  to  close  by  granulation  tissue  at  an  earlier  or 
later  period.  The  method  of  Panse  ( see  plate  XXVII )  is  most 
suitable  in  cases  where  the  posterior  opening  is  to  be  main- 
tained for  some  time  or  where  it  is  to  be  kept  permanently 
open,  as  it  gives  ready  access  to  the  entire  cavity  in  the  bone, 
and  by  using  this  method  the  meatal  opening  may  be  made  as 
large  as  desired,  as  any  moderate  deformity  which  may  be 
thus  produced  is  to  a  great  extent  hidden  by  the  antitragus. 
While  it  is  of  especial  value  in  those  cases  where  on  account 
of  the  extensive  area  involved  by  the  diseased  process,  one 
can  not  be  perfectly  sure  that  all  the  carious  bone  has  been 
removed,  as  this  procedure  covers  only  the  edges  of  the 
osseous  cavity  and  any  further  caries  which  may  recur  under 
such  circumstances  may  be  readily  thrown  off  or  seen  and 
properly  treated.  To  make  the  flaps  as  recommended  by  this 
operator,  a  pair  of  forceps  are  passed  into  the  external  mem- 
braneous canal  throughout  its  entire  length,  so  that  one  por- 
tion of  the  instrument  is  within  the  membraneous,  the  other 


348  Suppuration  of  the  Middle  Ear. 

on  the  outside  of  this  tube,  and  with  a  blunt  knife  the  canal 
is  divided  parallel  with  its  walls  along  the  entire  length  of 
its  posterior  wall  to  the  posterior  edge  of  the  external  meatus. 
This  incision  is  as  long  as  necessary  to  make  a  fair-sized 
meatal  opening  if  the  bone  cavity  be  not  too  large,  but  if 
a  large  amount  of  osseous  tissue  has  been  removed  from  the 
mastoid  process  the  opening  will  not  be  sufficient,  and  then 
one  must  lengthen  the  incision  in  the  posterior  wall  of  the 
canal,  so  that  it  extends  somewhat  into  the  concha.  At  the 
termination  of  the  external  end  of  the  incision,  two  shorter 
incisions  are  made  at  right  angles  to  it,  one  being  directed 
upwards,  the  other  in  a  downward  direction,  so  that  two 
flaps  are  thus  cut  out  of  the  tissues.  As  these  flaps  are 
somewhat  rigid  and  immovable,  they  are  now  thinned  down 
by  cutting  away  a  portion  of  the  tissue  on  their  posterior 
aspect  with  curved  scissors  and  the  inferior  flap  is  then 
attached  to  the  anterior  portion  of  the  osseous  cavity,  which 
is  in  intimate  connection  with  its  inferior  border,  by  means 
of  one  or  more  gut  sutures  as  may  be  necessary.  The  supe- 
rior flap  is  placed  in  position  in  the  same  manner  against  the 
upper  wall  of  the  tympanum  and  osseous  canal  and  it  may 
be  held  in  place  with  sutures  as  used  in  the  other  flap.  In 
those  cases  where  it  is  desired  from  the  onset  to  maintain  a 
permanent  retro-auricular  opening,  the  epithelial  surfaces 
of  both  flaps  should  be  brought  into  immediate  contact  with 
the  skin  surface  of  the  incision  over  the  mastoid  process  and 
there  retained  by  sutures,  but  this  procedure  should  not  be 
adopted  when  it  is  desired  to  close  the  mastoid  wound  by 
granulation,  as  under  such  circumstances  a  definite  area  of 
exposed  tissue  should  be  allowed  to  intervene  between  the 
flaps  and  the  skin  surface  of  the  posterior  opening. 

In  the  Koerner  plastic  operation  (see  plates  XXXIII 
and  XXXIV)  the  mastoid  incision  is  closed  at  once,  so 
that  healing  by  primary  intention  may  be  obtained,  and  as 


EXPLANATORY    NOTE    TO    PLATE    XXXIII. 


This  plate  shows  the  Koerner  flap  operation. 

1,  The  first  incision  along  the  upper  border  of  membrane-cartilaginous  auditory 
canal. 

2.  Dotted  line  indicating  the  lower  second  incision. 

35° 


PLATE  XXXIII 


EXPLANATORY    NOTE    TO    PLATE    XXXIV. 


This  plate  shows  the  completed  Koerner  flap  operation  with  the  flap  retracted  and 
ready  to  be  placed  in  position. 

i,  Forceps  holding  the  thinned  flap  made  from  the  posterior  membrano-carti- 
laginous  canal  wall. 

352 


PLATE  XXXIV 


Retro- Auricular  Opening  and  Plastic  Methods.  353 

it  produces  four  areas  from  which  epidermization  can  take 
place,  it  affords  a  rapid  method  as  compared  with  some 
other  plastic  procedures,  of  healing  the  suppurating  cavity 
in  those  cases  where  the  operator  entertains  no  doubt 
but  that  all  the  carious  bone  has  been  eradicated  when  the 
flaps  are  placed.  Should  this  method  be  employed  and  any 
diseased  tissue  be  allowed  to  remain,  the  flap  over  such  an 
area  is  very  certain  to  break  down  and  this  becomes  espe- 
cially unfortunate  in  those  cases  where  there  is  a  tendency 
towards  the  contraction  of  the  external  meatus,  although 
this  can  be  overcome  to  some  extent  by  the  employment 
of  a  large  drainage  tube  during  the  course  of  the  after 
treatment.  In  this,  as  in  other  similar  procedures,  the  size 
of  the  meatal  opening  depends  to  a  great  extent  upon  the 
extension  of  the  incision  outwards  into  the  concha  and  to 
a  lesser  degree  upon  the  tamponading  of  the  parts.  When 
there  is  some  degree  of  absorption  taking  place,  this  opening 
may  gradually  increase  in  size,  so  that  at  a  later  period  it 
becomes  larger  than  at  the  time  of  operation  and  the  inte- 
rior of  the  bone  cavity  can  be  readily  seen  in  all  its  parts, 
while  the  facility  of  thus  treating  the  parts  is  enhanced  by 
the  bending  backwards  of  the  cut  cartilage  of  the  auricle, 
which  is  an  essential  part  of  this  method.  To  perform  the 
Koerner  plastic  operation  two  clamps  are  employed  in  the 
following  manner :  the  branch  of  one  of  the  clamps  is  placed 
in  the  canal  and  the  other,  which  has  a  long  fenestration, 
is  placed  in  such  a  position  that  it  will  be  in  contact  with 
the  posterior  surface  of  the  fibrous  tube  and  holds  the  canal 
as  far  down  inferiorly  as  possible.  The  second  clamp  is 
then  applied  above  so  as  to  fix  the  canal  wall  in  this  position, 
and  with  a  pointed  knife  an  incision  is  made  the  length  of 
the  opening  in  both  the  lower  and  upper  clamps,  when  the 
instruments  are  then  removed.  In  order  to  obtain  flaps  of 
the  proper  shape  and  size,  the  two  parallel  incisions  should 
24 


354  Suppuration  of  the  Middle  Ear. 

be  from  a  quarter  to  three-eighths  of  an  inch  apart  from 
each  other,  and  after  the  clamps  have  been  removed,  both 
incisions  should  be  extended  well  out  into  the  tissues  of  the 
concha.  The  flap  thus  formed  is  made  more  flexible  and 
thinner  by  cutting  away  a  portion  of  the  tissue  from  its  pos- 
terior aspect,  as  in  the  Panse  flap,  and  it  is  turned  back  so 
that  it  accurately  fits  into  the  posterior  surface  of  the  osseous 
cavity.  In  order  to  place  and  retain  the  flap  in  the  desired 
position,  a  large  rubber  drainage  tube,  which  has  been  split 
for  its  entire  length,  is  placed  in  the  external  canal  with  the 
cut  portion  looking  towards  the  anterior  wall  and  the  flap 
is  in  contact  with  the  posterior  aspect  of  the  tube.  By  push- 
ing this  backwards  the  flap  is  held  in  position  when  the 
auricle  is  replaced  and  the  tampons  applied.  In  order  that 
the  flap  retains  its  position  and  is  not  loosened  when  the 
gauze  packing  and  drainage  tube  are  later  removed  at  the 
first  dressing,  the  flap  should  be  tamponed  through  the  tube 
with  small  strips  of  iodoform  gauze,  so  that  both  the  rubber 
tube  and  the  flap  are  firmly  held  against  the  posterior  aspect 
of  the  osseous  cavity.  When  the  gauze  packing  has  been 
completed  in  this  manner,  the  mastoid  incision  is  closed  with 
sutures  and  the  usual  dressings  are  applied,  the  rubber 
drainage  tube  being  allowed  to  remain  in  position  until  the 
flap  is  adherent  to  the  bony  walls,  when  it  can  then  be  taken 
away,  this  often  being  possible  at  the  first  dressing  subse- 
quent to  the  operation.  Politzer  changes  a  part  of  this  oper- 
tion  to  some  extent,  in  order  to  lessen  the  irregular  size  of 
the  external  opening  of  the  canal  which  results  from  the 
bending  back  of  the  cartilage  of  the  concha,  by  making  two 
short  incisions  in  the  cartilage  of  the  auricle  and  the  meatus, 
starting  from  the  external  extremities  of  the  first  incision. 
By  modifying  the  procedure  in  this  way  the  meatal  opening 
of  the  canal  is  also  somewhat  enlarged  in  the  same  direction 
and  for  a  similar  purpose  the  latter  operator  excises  a  small 
piece  of  cartilage  from  the  crus  helicis. 


EXPLANATORY    NOTE    TO    PLATE    XXXV. 


This  plate  shows  the  position  of  the  bistoury  in  making  the  first  incision  in  the 
Jansen  modification  of  the  Stacke  flap  operation. 


356 


PLATE  XXXV 


EXPLANATORY    NOTE    TO    PLATE    XXXVI. 


This  plate  shows  a  step  in  the  Jansen-Stacke  flap  operation.  The  first  incision 
having  been  completed,  the  ear  is  retracted  and  the  cartilaginous  canal  is  exposed  in 
the  field  of  the  completed  radical  operation. 


358 


PLATE  XXXVI 


EXPLANATORY    NOTE    TO    PLATE    XXXVII. 


This  plate  shows  the  second  incision  in  the  Jansen-Stacke  flap  operation.  The 
scissors  introduced  along  the  dotted  line  indicating  the  longitudinal  incision.  The 
Panse  flap  consists  in  making  an  incision  at  equal  distances  from  the  upper  and  lower 
ends  of  the  first  (vertical)  incision. 

A — B,  First  incision  ;  C — D,  second  incision  ;  E — F,  Panse  method. 

360 


PLATE  XXXVII 


EXPLANATORY    NOTE    TO    PLATE    XXXVIII. 


This  plate  shows  the  Jansen-Stacke  flap   operation   completed,   the  flaps   being 
placed  in  position. 

i,  The  small  upper  flap;  2,  large  lower  flap. 

362 


PLATE  XXXVIII 


Retro-Auricular  Opening  and  Plastic  Methods.  363 

In  addition  to  what  has  previously  been  pointed  out  in 
regard  to  the  Stacke  operation,  it  is  here  desired  to  briefly 
describe  two  plastic  methods  suggested  by  that  operator. 
The  first  of  these  is  made  from  the  tissues  of  the  mem- 
braneous auditory  canal  and  consists  of  a  single  longitudinal 
incision  made  through  the  entire  length  of  the  superior  wall 
of  the  canal  as  far  outwards  as  the  concha.  Close  to  the 
concha  and  at  right  angles  to  this  incision,  a  second  incision 
in  the  tissues  is  made  in  a  downward  direction,  so  that  a  rec- 
tangular flap  is  formed,  composed  of  the  posterior  and  a 
part  of  the  superior  walls  of  the  fibrous  canal.  This  is  then 
pressed  against  the  inferior  and  posterior  surfaces  of  the 
osseous  cavity  and  is  held  in  place  by  tampons  of  gauze  in- 
serted through  the  enlarged  auditory  canal,  while  in  those 
cases  where  it  is  necessary  to  maintain  a  permanent  retro- 
auricular  opening,  the  external  angle  of  the  canal  flap  is 
sutered  to  the  inferior  angle  of  the  mastoid  incision.  Jansen 
modifies  this  procedure  by  reversing  the  order  of  the  incis- 
ions (see  plates  XXXV,  XXXVI,  XXXVII  and  XXXVIII). 
The  second  plastic  operation  advised  by  Stacke  is  also  em- 
ployed to  line  the  mastoid  cavity  and  is  composed  of  both  skin 
and  periosteum,  and  unlike  the  former  flap  methods,  the  tissue 
is  taken  from  over  the  mastoid  surface  instead  of  from  the 
membraneous  auditory  canal.  Previous  to  the  performance 
of  the  radical  operation  on  the  osseous  structures,  a  large 
tongue-shaped  dermal  flap  is  cut  out  from  the  mastoid  sur- 
face by  an  incision  including  the  skin  and  subcutaneous 
tissue.  The  flap  thus  produced  has  the  apex  directed  down- 
wards, with  its  large  base  above  over  the  temporal  line.  A 
tongue-shaped  flap  is  then  made  from  the  periosteum  of  the 
mastoid  region  by  two  diverging  incisions  extending  down- 
wards, so  that  the  base  of  the  reverse  of  the  skin  flap  is 
placed  at  the  insertion  of  the  sterno-mastoid  muscle  and  the 
apex  at  the  temporal  ridge.  The  superior  flap,  which  is 


364  Suppuration  of  the  Middle  Ear. 

composed  of  skin  and  subcutaneous  tissue,  is  then  placed  in 
position  over  the  roof  of  the  tympanic  cavity  and  antrum, 
while  the  second  flap  of  periosteum  is  made  to  cover  the 
floor  of  the  antrum  and  as  much  as  possible  of  the  facial 
spur,  the  final  step  of  this  procedure  being  the  transplanta- 
tion of  skin  grafts  on  the  granulating  surface  of  the  perios- 
teal  flap. 

Siebermann  alters  Stacke's  canal  flap  operation  by  con- 
tinuing the  original  incision  out  into  the  concha  in  a  Y-shape, 
so  that  three  flaps  are  formed.  In  order  to  apply  these  flaps 
to  the  desired  position,  the  small  middle  flap,  which  com- 
prises the  cartilage  of  the  concha  is  cut  out  and  the  parts 
are  then  maintained  in  position  with  gauze  tampons.  Sie- 
bermann's  original  plastic  method  is  somewhat  more  difficult 
to  perform  than  the  usual  flap  operations  and  it  is  to  be 
employed  only  in  those  cases  where  it  is  desired  to  form  a 
persistent  retro-auricular  fistula.  He  first  makes  the  usual 
Stacke  flap  and  fastens  the  short  edges  of  this  to  the  lower 
angle  of  the  mastoid  wound,  so  that  the  meatal  flap  is  at- 
tached to  the  anterior  edge  of  the  mastoid  opening  at  its 
inferior  part.  The  free  edge  of  the  concha  is  then  protected 
by  the  dermal  surface  of  both  the  anterior  and  posterior  parts 
of  the  auricle  and  a  movable  flap  is  then  made  from  over 
the  mastoid  region.  This  retro-auricular  flap  is  made  with 
its  base  directed  upwards  towards  the  temporal  line,  its  apex 
is  directed  downwards  and  after  it  has  been  dissected  free 
it  is  tamponed  into  the  osseous  cavity  from  behind  and  above. 
All  the  walls  of  the  cavity  from  which  the  morbid  tissue  has 
been  removed  which  still  remain  unprotected  and  also  the 
defect  behind  the  ear  are  then  covered  with  skin  grafts  in 
the  usual  manner. 

For  the  production  of  the  persistent  retro-auricular  open- 
ing, Kretschmann's  plastic  operation  may  also  be  employed, 
the  flaps  being  formed  by  this  procedure  according  to  the 


Retro-Auricular  Opening  and  Plastic  Methods.   365 

method  recommended  by  Panse,  but  in  addition  to  this  a  skin 
flap  is  also  formed.  This  latter  flap  is  made  from  the  dermal 
surface  of  the  posterior  edge  of  the  mastoid  opening  and  is 
drawn  down  into  the  bone  cavity  by  a  curved  incision  in  the 
skin  parallel  to  the  back  edge  of  the  mastoid  wound  and 
extending  externally  to  the  line  of  the  hair.  A  short  in- 
cision is  then  made  from  the  center  of  the  original  incision 
connecting  it  with  the  edge  of  the  mastoid  wound,  so  that 
two  flaps  are  thus  produced  which  are  turned  into  the  osseous 
cavity  from  above  and  below,  after  they  have  been  dissected 
loose. 

Passow,  in  performing  his  plastic  flap  operation,  at  first 
makes  the  Stacke  flaps  in  an  inverted  manner  from  the  pos- 
terior wall  of  the  fibro-cartilaginous  canal  and  then  turns 
the  flap  which  is  thus  made  in  an  upward  direction  against 
the  upper  wall  of  the  mastoid  cavity,  where  it  is  held  in  posi- 
tion by  the  usual  gauze  tampon  and  the  short  edge  of  the 
flap  is  joined  to  the  cut  border  of  the  concha.  Following  this 
a  skin  flap  is  formed  from  the  tissue  over  the  mastoid  process 
which  is  turned  up  so  that  its  posterior  border  is  brought  into 
contact  with  the  parts  remaining  of  the  lower  wall  of  the 
external  canal,  the  tissues  being  held  together  here  by  gut 
sutures.  The  anterior  edge  of  this  flap  is  then  sutured  to 
the  posterior  border  of  the  mastoid  opening  and  the  open 
area  remaining  as  the  result  of  cutting  this  flap  away  is 
brought  together  and  sutured  in  the  usual  manner,  while  the 
cut  edges  of  the  concha  which  still  remain  are  covered  by  the 
skin  of  both  surfaces  of  the  auricle. 

In  those  cases  where  it  is  necessary  to  see  every  part  of  a 
large  osseous  cavity  and  a  post-auricular  opening  is  not  de- 
sired, Grunert  and  Zeroni  have  devised  a  method  of  obtain- 
ing a  permanently  large  meatal  opening,  so  that  if  necessary 
the  mastoid  wound  can  be  closed  at  an  early  period  This 
is  accomplished  by  making  a  longitudinal  incision  the  entire 


366  Suppuration  of  the  Middle  Ear. 

length  of  the  membraneous  auditory  canal  and  carrying  it 
outwards  far  into  the  concha.  The  conchal  end  of  the  in- 
cision is  then  allowed  to  granulate  to  a  slight  extent,  but  not 
to  the  degree  that  firm  cicatricial  tissue  is  produced  and  the 
meatus  thus  formed  is  gradually  subjected  to  daily  dilatation 
with  tampon  and  speculum,  so  that  after  a  time  a  large  round 
external  opening  to  the  canal  is  obtained.  They  have  devised 
a  specially  constructed  speculum  for  the  purpose  of  dilata- 
tion, it  being  almost  a  cylinder  in  form  and  is  much  larger 
than  any  of  the  specula  usually  employed  by  the  otologist, 
and  as  the  parts  should  be  redressed  daily  so  that  the  cavity 
may  be  treated  and  cleansed  and  a  new  tampon  inserted,  the 
specula  is  introduced  at  each  treatment  and  allowed  to  remain 
for  a  short  space  of  time,  until  the  meatus  has  reached  the 
large  size  desired.  On  account  of  the  soft  granulation  tissue 
filling  the  incision  in  the  concha,  the  parts  here  are  extremely 
extensible  and  readily  submit  to  the  dilatation,  so  that  both 
the  cartilaginous  meatus  and  canal  permit  of  a  rapid  increase 
of  their  size  without  any  very  serious  disfigurement  nor  later 
contraction  as  one  might  naturally  expect.  When  the  meatal 
opening  has  been  dilated  to  a  sufficient  size,  all  parts  of  the 
osseous  cavity  can  be  readily  seen  through  it  and  the  dilata- 
tion must  be  continued  until  this  has  been  accomplished. 
The  retro-auricular  opening  should  be  maintained  at  first,  so 
that  through  it  those  portions  of  the  cavity  can  be  examined 
which  can  not  be  seen  through  the  meatus  before  it  has  been 
sufficiently  dilated  and  it  is  also  wise  to  keep  it  open  for  a 
time  at  least,  so  that  one  can  see  that  the  tampons  are  care- 
fully placed,  although  these  should  be  inserted  through  the 
meatus.  In  several  cases  where  Grunert  allowed  the  mas- 
toid  opening  to  heal  by  primary  union,  considerable  difficulty 
later  arose,  as  perichondritis,  with  or  without  small  localized 
pus  collections,  developed  in  the  neighborhood  of  the  external 
auditory  canal  and  so  narrowed  it  temporarily  that  it  became 


Retro-Auricular  Opening  and  Plastic  Methods.  367 

impossible  to  see  the  interior  of  the  osseous  cavity  to  any 
extent  and  at  the  same  time  the  employment  of  the  large 
speculum  for  purposes  of  dilatation  had  to  be  temporarily 
abandoned.  The  further  treatment  of  the  mastoid  opening 
varies  entirely  with  the  degree  of  dilatation  that  is  obtained 
of  the  meatus,  and  as  this  becomes  larger  in  size,  the  latter 
opening  may  be  allowed  to  contract,  so  that  it  will  be  still 
of  sufficient  size  to  allow  those  parts  to  be  visible  which  can- 
not be  seen  through  the  auditory  canal.  Finally,  when  the 
entire  osseous  cavity  can  be  seen  in  all  its  detail  through  the 
now  enlarged  meatus,  the  retro-auricular  opening  may  be 
allowed  to  close  completely  by  omitting  the  tampon  here, 
for  if  it  be  tamponed  frequently  so  that  its  borders  do  not 
become  covered  with  a  firm  layer  of  epithelial  cells,  it  may 
be  maintained  at  practically  any  size  that  may  be  desired  and 
for  an  indefinite  period  of  time. 

The  retro-auricular  opening  following  the  radical  opera- 
tion for  chronic  suppurative  otitis  has  a  value  that  is  some- 
what problematical  and  the  presence  or  absence  of  such  an 
opening  depends  in  many  cases  to  a  very  great  extent  upon 
the  particular  views  held  by  the  surgeon  in  this  respect. 
Passow  states  that  the  ideal  aim  of  the  radical  operation  is 
the  suppression  of  the  suppuration  by  the  complete  epidermi- 
zation  of  the  whole  cavity  which  forms  the  operative  field 
and  the  preferable  method  is  that  which  reaches  this  object 
most  surely  and  rapidly.  He  believes  that  primary  union 
destroys  almost  completely  the  results  of  the  operation;  that 
late  suture  offers  but  little  more  advantage,  but  that  the  free 
retro-auricular  opening  should  be  preserved  in  order  to  place 
the  patient  beyond  the  chances  of  recurrence  and  danger  and 
to  facilitate  the  after  treatment.  When  the  surgeon  is  abso- 
lutely sure  that  after  a  radical  operation  he  has  removed  all 
the  diseased  tissues  in  every  respect,  then  in  such  cases  the 
retro-auricular  opening  is  not  at  all  necessary  or  even  desir- 


368  Suppuration  of  the  Middle  Ear. 

able,  but  unfortunately  one  cannot  always  be  sure  that  so 
perfect  an  operation  has  been  performed,  especially  when 
there  has  been  a  great  destruction  of  the  temporal  bone  with 
cholesteatomatous  formation,  and  under  these  circumstances 
it  is  wiser  to  maintain  such  an  opening  for  a  year  or  more  at 
least.  Among  the  main  objects  for  the  maintenance  of  such 
an  opening,  the  simplicity  of  the  after  treatment  which  it 
affords  is  of  importance,  every  portion  of  the  osseous  cavity 
is  open  to  tamponage  and  all  the  minor  depressions  and  irreg- 
ularities can  readily  be  seen,  and  if  diseased,  treated,  while 
secondary  operations  if  necessary  are  easy  to  perform.  In 
the  average  case  it  rarely  requires  more  than  three  or  four 
months  to  obtain  a  perfect  recovery,  and  if  the  opening  be 
made  as  small  as  the  necessities  of  the  case  will  admit,  but 
little  deformity  will  be  noticed.  In  the  great  majority  of 
cases  the  main  object  of  maintaining  the  retro-auricular 
opening  is  the  fear  of  the  redevelopment  of  cholesteatoma, 
and  when  this  condition  is  present  in  any  suppurative  case, 
it  is  often  necessary  to  maintain  the  opening  until  every  par- 
ticle of  the  epithelial  proliferation  has  been  removed  and 
there  remains  no  tendency  to  its  recurrence.  Politzer  states 
the  objects  of  the  posterior  opening  as  follows:  endeavor 
to  bring  about  a  persistent  opening  behind  the  ear  lined  with 
epidermis  when  there  is  extensive  cholesteatoma  in  the  mas- 
toid,  by  which  the  greater  part  of  the  mastoid  is  destroyed 
and  a  cavity  reaching  far  posteriorly  and  superiorly  is 
formed,  as  such  an  opening  enables  us  to  remove  cholestea- 
tomatous deposits  resulting  from  the  process  of  epidermi- 
zation  and  which  lie  in  the  recesses  of  the  cavity  better  than 
by  way  of  the  external  auditory  canal,  the  patient  also  being 
better  enabled  to  wash  out  the  ear  and  thus  preventing  the 
formation  of  crusts  and  deposits  of  epidermis.  The  same 
author  also  states  that  when  there  are  cholesteatomatous 
masses,  when  the  antrum  is  markedly  widened  posteriorly 


EXPLANATORY    NOTE    TO      PLATE    XXXIX. 


This  plate  shows  the  first  step   in   the  performance   of  the   Passow-Trautmann 
plastic  operation  for  the  closure  of  a  persistent  retro-auricular  opening. 


370 


PLATE  XXXIX 


EXPLANATORY    NOTE    TO    PLATE    XL. 


This  plate  shows  the  second  step  in  the  performance  of  the  Passow-Trautmann 
plastic  operation  for  the  closure  of  a  persistent  retro-auricular  opening. 


372 


PLATE  XL 


EXPLANATORY    NOTE    TO    PLATE    XLI. 


This  plate  shows  the  third  step  and  completion  of  the  Passow-Trautmann  plastic 
operation  for  the  closure  of  a  persistent  retro-auricular  opening. 


374 


PLATE  XLI 


Retro- Auricular  Opening  and  Plastic  Methods.   375 

and  superiorly,  and  when  there  is  a  great  loss  of  substance 
of  the  vertical  portion  of  the  mastoid  process,  it  is  better  at 
first  to  leave  the  wound  open  so  it  can  be  closed  later  by 
suture,  if  favorable,  or  allowed  to  close  by  itself,  the  tem- 
porary keeping  open  of  the  wound  affording  a  better  chance 
of  observing  the  course  of  the  opening,  more  easily  treating 
it  and  in  addition  one  can  obtain  a  general  view  of  the  effects 
of  the  treatment. 

Various  methods  of  forming  the  retro-auricular  opening 
have  already  been  described  in  detail  and  it  may  be  seen  as 
a  general  principle  that  should  the  surgeon  desire  the  wound 
in  the  mastoid  process  to  remain  open,  it  is  essential  that  he 
use  pedunculated  grafts  of  various  sorts  and  that  the  tampon 
be  applied  directly  through  the  opening,  while  in  cases  where 
this  is  not  desired,  skin  grafting  may  be  used  to  obtain  an 
early  closure,  which  will  take  place  quite  rapidly  if  the  tam- 
pons of  gauze  are  employed  exclusively  through  the  meatus. 
Reinhardt  found  in  cholesteatoma  that  where  the  opening 
rapidly  closed  a  new  formation  and  disintegration  of  epi- 
thelial tissue  set  in,  while  in  those  cases  where  the  opening 
was  retained  this  never  happened,  his  methods  of  main- 
taining the  opening  in  such  cases  being  by  means  of  flaps 
of  skin  from  the  patient's  head,  by  transplantation  from  ani- 
mals and  by  means  of  grafts  from  the  posterior  surface  of 
the  concha.  As  previously  stated,  the  main  object  of  the 
retro-auricular  opening  is  to  obtain  the  complete  epidermi- 
zation  and  which  lie  in  the  recesses  of  the  cavity,  better  than 
exposed  by  the  operation.  It  is  readily  appreciated  that  the 
more  this  is  covered  with  epithelium  the  more  rapid  healing 
will  take  place  and  the  less  bone  that  thus  is  exposed,  the 
less  will  be  the  danger  of  its  further  destruction  by  the 
carious  process.  In  all  these  plastic  operations  it  is  an  in- 
variable rule  that  the  more  epidermis  that  is  placed  in  the 
cavity,  the  more  rapidly  and  promptly  will  the  process  of 
epidermization  take  place. 


376  Suppuration  of  the  Middle  Ear. 

A  method  of  producing  this  result,  which  has  been  suc- 
cessfully employed  consists  in  making  a  U-shaped  incision 
beginning  in  front  of  and  extending  around  the  tip  of 
the  mastoid  process  and  the  dermal  layer  thus  incised  is 
dissected  up  so  that  it  forms  a  flap  with  the  base  above. 
The  periosteal  layer  is  then  dissected  away  in  the  same 
manner  except  that  it  is  cut  completely  across  at  the  top 
and  base  is  formed  below;  thus  two  flaps  are  produced 
which  can -be  tamponed  into  the  cavity  made  in  the  bone 
after  all  the  diseased  tissues  have  been  chiseled  and  curetted 
away.  Should  the  skin  over  the  mastoid  process  be  much 
involved,  or  for  any  reason  it  is  not  considered  advisable 
to  employ  it  for  such  purposes,  flaps  may  be  taken  from 
the  tissues  of  the  cervical  region,  or  another  method  which 
is  sometimes  applicable,  is  to  dissect  up  a  skin  flap  from  the 
surface  posterior  to  the  mastoid  and  by  turning  this  back- 
wards the  underlying  periosteum  may  be  turned  up  as  a 
flap,  with  its  base  at  the  posterior  border  of  the  opening 
in  the  bone,  when  it  may  be  then  packed  into  the  cavity  and 
the  skin  flap  overlying  it  is  then  replaced  in  its  normal  situa- 
tion. The  use  of  periosteal  flaps  alone  for  lining  the  cavity 
in  the  bone  is  however  not  to  be  recommended,  as  by  their 
use  in  this  way  one  does  not  obtain  the  desired  epithelial 
surface,  but  when  used  in  connection  with  dermal  flaps  they 
may  often  prove  of  value  in  covering  the  bare  bone  until 
epidermization  extends  from  other  centers.  With  aseptic 
technique  and  the  consequent  thoroughness  with  which  ex- 
tensive portions  of  the  temporal  bone  can  be  removed,  the 
necessity  for  a  permanent  retro-auricular  opening  in  many 
cases  is  steadily  diminishing,  especially  as  there  are  many 
serious  objections  to  it,  not  the  least  of  which  is  the  disfigure- 
ment produced.  While  this  latter  objection  is  not  so  marked 
when  the  opening  is  small,  yet  it  holds  good  in  a  large  open- 
ing and  in  the  latter  instance  there  also  exists  a  certain  ten- 


EXPLANATORY    NOTE    TO    PLATE    XLII. 


This  plate  shows  the  first  step  in  the  performance  of  the  Mosetig-Moorhof  plastic 
operation  for  the  closure  of  a  persistent  retro-auricular  opening. 


378 


PLATE  XLII 


EXPLANATORY    NOTE    TO    PLATE    XLIII. 


This  plate  shows  the  second  step  in  the  performance  of  the   Mosetig-Moorhof 
plastic  operation  for  the  closure  of  a  persistent  retro-auricular  opening. 


380 


PLATE  XLIII 


EXPLANATORY    NOTE    TO    PLATE    XLIV. 


This  plate  shows  the  third  step  in  the  performance  of  the  Mosetig-Moorhof  plastic 
operation  for  the  closure  of  a  persistent  retro-auricular  opening. 


382 


PLATE  XLIV 


EXPLANATORY    NOTE    TO    PLATE    XLV. 


This  plate  shows  the  completion  of  the  Mosetig-Moorhof  plastic  operation  for 
the  closure  of  a  persistent  retro-auricular  opening. 


384 


PLATE  XLV 


Retro-Auricular  Opening  and  Plastic  Methods.  385 

dency  to  relapse  of  the  suppuration.  Vulpius  believes  that 
it  is  neither  desirable  nor  necessary  in  the  treatment  of  cho- 
lesteatoma  to  retain  an  opening  behind  the  ear  and  this 
belief  is  being  more  and  more  coincided  in  by  many  otolo- 
gists, while  in  contradistinction  to  the  permanent  opening  are 
the  advantages  of  the  primary  union  of  the  post-aural  in- 
cision, in  that  it  is  not  necessary  to  have  the  patient  wear  the 
bandages  for  any  long  period  of  time  and  that  he  can  go 
about  his  occupation  within  a  very  short  time  after  the  opera- 
tion. A  great  objection  to  the  retro-auricular  opening  is 
the  necessity  for  frequent  dressing  and  tamponing  and  espe- 
cially the  excessive  pain  which  is  thus  daily  produced  by  the 
majority  of  methods  commonly  employed,  the  recent  trend 
of  opinion  in  this  respect  being  that  except  in  exceptional 
cases  there  is  no  absolute  need  for  the  maintenance  of  the 
retro-auricular  opening,  and  with  some  of  the  modern  plastic 
methods  of  lining  the  osseous  cavity  from  the  tissue  of  the 
membraneous  auditory  canal,  a  complete  view  of  the  parts 
through  the  somewhat  enlarged  meatus  can  be  obtained  with 
a  permanent  cure  of  the  chronic  suppurative  otitis. 

The  time  at  which  the  opening  behind  the  ear  should  be 
closed  will  depend  entirely  upon  the  amount  of  diseased  tissue 
that  still  remains,  or  the  degree  of  cicatrization  of  the  cavity 
in  the  bone.  It  is  as  a  rule  safer  to  err  on  the  side  of  safety, 
and  allow  the  opening  to  remain  longer  than  necessary  than 
to  close  it  at  too  early  a  period.  A  point  which  may  be  of 
value  in  deciding  this,  being  the  size  of  the  meatal  opening,  as 
when  this  is  of  a  size  sufficient  to  see  and  treat  all  the  interior 
of  the  operative  field,  then  there  is  no  necessity  for  retaining 
the  post-auricular  opening.  When  a  low  grade  of  osteitis 
continues  after  the  operation,  it  is  of  course  necessary  to 
keep  the  opening  patent  until  the  osseous  tissue  again  reaches 
a  normal  condition  and  no  evidences  of  suppuration  can  be 
found  by  the  most  scrupulous  examination  and  the  cavity 

26 


386  Suppuration  of  the  Middle  Ear. 

of  the  wound  is  covered  with  a  firm,  dry,  adherent  epithelial 
lining  which  is  not  eczematous  and  does  not  produce  an 
excessive  amount  of  desquamation.  When  cholesteatoma 
has  been  present  and  the  posterior  opening  has  been  main- 
tained to  prevent  its  redevelopment,  one  can  not  definitely 
say  in  advance  in  any  given  case  the  time  at  which  the  open- 
ing may  be  allowed  to  close,  some  operators  considering  that 
after  one  or  two  years,  if  there  has  been  no  return  of  the 
trouble,  it  will  be  safe  to  perform  a  plastic  operation  for  its 
closure,  but  it  should  always  remain  open  in  every  case  in 
which  it  is  employed  until  there  is  absolutely  no  sign  of  the  re- 
turn of  additional  cholesteatomatous  formation.  As  has  been 
previously  pointed  out,  the  time  that  it  takes  for  the  epiderm- 
ization  of  the  cavity  depends  to  a  considerable  extent  upon 
the  plastic  operation  which  has  been  employed,  that  is,  upon 
the  amount  of  healthy  epithelial  tissue  that  has  been  placed 
in  the  wound  and  has  successfully  "taken,"  but  even  then 
when  this  has  been  accomplished,  only  after  continuous 
observation  for  a  long  time,  when  one  is  sure  that  the  des- 
quamation is  but  trifling  and  that  new  deposits  of  prolifer- 
ating epithelium  can  be  readily  removed  through  the  external 
auditory  canal  can  the  cavity  behind  the  auricle  be  safely 
closed,  Passow  stating  that  when  there  is  cholesteatoma  he 
closes  the  fistula  after  the  lining  has  remained  healthy  and 
free  from  irritation  for  six  months  or  a  year,  while  in  those 
cases  where  eczema  is  intractable  or  the  superficial  layer  of 
the  epithelium  still  persists  in  excessive  proliferation,  the 
opening  is  allowed  to  remain  indefinitely. 

In  order  to  permanently  close  the  retro-auricular  open- 
ing skin  grafting  may  be  employed  by  any  of  the  methods 
previously  described,  or  the  plastic  operations  of  Lermoyez, 
Trautmann  or  Politzer  have  been  successfully  used  in  a 
number  of  instances.  The  procedure  employed  by  Lermoyez 
and  Mahn  is  performed  under  general  anaesthesia.  The 


Retro-Auricular  Opening  and  Plastic  Methods.   387 

side  of  the  head  is  shaved  and  rendered  surgically  clean  in 
the  usual  manner  previous  to  operation.  Posterior  to  the 
opening  in  the  mastoid  process,  the  skin  is  incised  through 
to  the  periosteum  about  a  half  centimeter  above  the  cavity; 
a  second  incision  identical  to  this  is  made  in  the  same  posi- 
tion below.  These  are  then  joined  by  two  other  incisions, 
so  that  a  trapezium-shaped  figure  is  formed  and  the  skin  is 
then  dissected  up  well  into  the  cavity  in  the  shape  of  two 
wings ;  these  are  then  turned  inwards  so  that  they  are  brought 
into  apposition  with  each  other  across  the  opening  in  the 
bone,  where  they  are  united  by  sutures,  so  that  the  fistula 
is  completely  occluded.  Where,  in  order  to  accomplish  this, 
considerable  tension  of  the  soft  tissues  takes  place,  it  becomes 
necessary  to  make  a  semilunar  incision  over  the  mastoid  about 
ten  or  fifteen  millimeters  from  the  border  of  the  original 
posterior  incision  and  the  usual  antiseptic  dressings  are  then 
applied.  Healing  as  a  rule  takes  place  in  less  than  a  week, 
and  a  firm  dermal  covering  over  the  opening  in  the  bone  is 
produced,  so  that  the  cavity  communicates  with  the  exterior 
only  by  means  of  the  external  auditory  canal  and  the  auricle 
is  not  displaced  in  any  way,  but  remains  in  its  normal 
position. 

Trautmann's  operation  (see  plates  XXXIX,  XL  and 
XLI)  for  the  same  purpose  is  also  performed  under  a 
general  anaesthetic  and  after  the  operative  field  including 
the  retro-auricular  opening  has  been  thoroughly  cleansed 
and  sterilized,  the  cavity  is  then  carefully  packed  with 
gauze  through  the  external  auditory  canal  to  protect  the 
parts  against  the  entrance  of  blood.  An  incision  about 
four  millimeters  long  is  then  made  in  the  center  of  the  upper 
and  lower  edges  of  the  bone  opening  and  extending  into 
the  cavity  in  the  direction  of  its  long  axis  for  two  milli- 
meters. A  second  incision  is  then  made,  commencing  at  the 
upper  incision  in  the  posterior  periphery  of  the  sinus  and 


388  Suppuration  of  the  Middle  Ear. 

terminating  in  the  lower  part  of  the  original  incision,  while 
another  incision  is  made  in  exactly  the  same  manner  at  the 
anterior  periphery.  The  two  incisions  thus  made  should  be 
placed  at  a  distance  of  four  millimeters  in  the  middle  of  their 
course  from  the  anterior  and  posterior  edges  of  the  retro- 
auricular  opening  and  should  extend  through  to  the  perios- 
teum behind  and  to  the  perichondrium  in  front.  The  pos- 
terior flap  thus  formed  is  loosened  with  the  elevator  and 
drawn  forwards  over  the  cavity  in  the  bone,  while  the  ante- 
rior flap  is  loosened  from  the  tissues  beneath  with  the  scalpel 
and  drawn  backwards  to  meet  the  posterior  flap.  As  the 
tensity  of  the  cutaneous  tissue  prevents  the  proper  approxi- 
mation of  the  flaps  for  the  final  suturing,  it  becomes  nec- 
essary to  loosen  up  the  soft  tissues  over  the  mastoid  for  this 
purpose,  and  when  this  has  been  accomplished,  both  the  ante- 
rior and  posterior  flaps  are  turned  into  the  opening  and 
isolated,  when  sutures  are  placed  twice  into  their  longitu- 
dinal axis,  so  that  a  total  of  four  sutures  are  placed  in  both 
the  anterior  and  posterior  flaps.  When  the  sutures  are 
placed  in  the  longitudinal  direction  but  little  difficulty  is  ex- 
perienced by  using  the  ordinary  slightly  curved  needle,  but 
when  they  are  placed  in  the  horizontal  direction  from  side 
to  side,  even  with  a  sharply  curved  needle,  great  difficulty  is 
usually  experienced.  The  ligatures,  which  may  be  designated 
as  number  two,  are  then  held  by  an  assistant  while  number 
one  are  tied,  then  number  four  are  held  while  number  three 
are  tied,  and  finally  number  four  are  tied  after  this  has  been 
done  with  number  two.  These  ligatures  should  be  of  catgut, 
while  the  skin  over  the  wound  is  sutured  with  sik.  The 
gauze  which  has  been  placed  in  the  osseous  cavity  is  then 
removed  and  a  fresh  gauze  packing  is  placed  by  way  of  the 
external  auditory  canal,  while  an  aseptic  dressing  is  applied 
over  the  entire  ear  and  allowed  to  remain  in  position  for 
five  days.  As  a  rule  the  skin  incisions  heal  by  first  inten- 


Retro-Auricular  Opening  and  Plastic  Methods.  389 

tion  and  when  the  dressings  are  first  changed,  it  will  be  found 
that  the  gauze  packing  in  the  canal  has  been  moistened  with 
a  bloody  serum.  The  second  dressing  is  then  allowed  to 
remain  in  place  for  two  days,  and  at  the  termination  of  one 
or  two  weeks  the  gauze  will  be  found  to  be  perfectly  dry, 
while  the  field  of  operation  has  become  permanently  cica- 
trized and  smooth,  so  that  when  the  auricle  is  retracted  the 
entrance  to  the  external  auditory  canal  becomes  considerably 
widened  and  the  various  parts  of  the  bone  cavity  can  be 
readily  seen. 

Other  methods  which  have  been  successfully  employed  by 
Politzer  and  described  by  him  are  as  follows:  A  tongue- 
shaped  flap  larger  than  the  defect  is  outlined  below  the 
retro-auricular  opening  on  the  skin  of  the  mastoid  in  the 
lateral  cervical  region  and  at  the  edges  of  the  line  mark- 
ing the  flap,  a  border  free  of  epidermis  and  about  two  mil- 
limeters in  width  is  made.  The  flap  is  then  dissected  up 
as  far  as  the  edge  of  the  defect  in  the  bone,  to  which  it  is 
connected  by  a  broad  pedicle,  and  to  make  sure  that  the  flap 
will  unite  with  the  edge  of  the  defect,  the  circumference  of 
the  opening  is  deepened  two  millimeters  in  a  furrow-like 
manner  by  a  pointed  bistoury.  The  flap  is  then  turned  up, 
and  after  its  edges  have  been  brought  into  the  furrow  around 
the  defect  in  the  bone,  it  is  fixed  by  four  sutures.  The  epi- 
dermal surface  of  the  skin  flap  is  thereby  turned  inwards, 
that  is,  towards  the  wound  cavity,  and  the  defect  from  the 
removal  of  the  flap  is  covered  by  uniting  the  edges  of  the 
incision  in  the  skin,  while  the  external  raw  surface  of  the 
flap  is  covered  with  Thiersch  grafts  or  allowed  to  cica- 
trize. This  method  is  known  as  the  Mosetig-Moorhof  opera- 
tion (see  plates  XLII,  XLIII,  XLIV  and  XLV).  Politzer 
also  advised  the  employment  of  Passow's  method,  which 
is  performed  under  local  anaesthesia  by  the  injection  of 
Schleich's  solution.  When  the  tissues  are  anaesthetized,  an 


390  Suppuration  of  the  Middle  Ear. 

oval  incision  is  made  around  the  edge  of  the  opening  down 
to  the  bone  behind  and  the  cartilage  in  front,  and  the  skin  is 
pushed  towards  the  wound  cavity  on  the  one  hand  and  away 
from  it  on  the  other,  so  that  two  movable  skin  flaps  are 
constructed:  an  internal  one  within  the  cavity  and  an  ex- 
ternal one  outside  of  it.  The  internal  flap  is  then  invagi- 
nated  into  the  wound  cavity  so  that  its  epidermal  surface 
faces  inwards  and  the  two  edges  are  united  by  a  single  line 
of  sutures.  In  the  same  way  the  external  skin  flaps  are 
drawn  together  by  sutures  until  they  meet  and  are  then 
united,  this  latter  method  only  being  indicated  when  the 
opening  in  the  mastoid  process  is  small,  as  when  it  is  of 
larger  size  it  is  not  always  possible  to  bring  the  edges  of 
the  external  flap  together. 


CHAPTER  VII. 

AFTER  TREATMENT  OF  MASTO1D 
OPERATIONS. 


391 


THE  AFTER  TREATMENT  OF  MASTOID  OPERATIONS. 

When  the  radical  operation  has  been  performed,  in  order 
to  obtain  a  permanent  cessation  of  the  discharge  in  a  case  of 
chronic  suppurative  otitis  media,  or  after  any  variety  of 
procedure  removing  osseous  tissue  for  the  same  end,  it  is 
always  of  great  importance  that  both  the  surgeon  and  patient 
fully  realize  that  the  operation  is  but  the  beginning  of  the 
treatment,  as  the  later  dressings  and  care  of  the  parts  con- 
stitute an  essential  link  in  the  chain  of  success,  the  object 
of  the  after  treatment  being  the  complete  epidermization  of 
the  cavity  formed  by  the  operation,  by  the  formation  at  first 
of  a  healthy  layer  of  granulation  tissue  covering  the  osseous 
walls  and  the  development  of  an  efficient  barrier,  so  that  any 
pyogenic  process  remaining  or  newly  forming  after  operation 
will  not  extend  to  more  vital  parts.  Not  only  should  the 
cavity  in  all  its  parts  be  protected  by  a  firm  layer  of  epithelial 
cells,  but  this  should  be  perfectly  smooth  and  also  remain 
unchanged  in  order  that  no  secretions  form,  or  excessive 
epithelial  desquamation  takes  place,  a  secondary  object,  both 
of  the  operation  and  after  treatment,  being  the  conservation 
of  the  hearing  as  far  as  possible,  although  this  factor  cannot 

393 


394  Suppuration  of  the  Middle  Ear. 

naturally  assume  any  great  importance  if  the  parts  be  exten- 
sively destroyed  by  the  suppurating  process  and  a  very  rad- 
ical removal  of  considerable  osseous  tissue  becomes  neces- 
sary. As  regards  the  radical  operation,  opinions  vary  con- 
siderably as  to  the  final  outcome  on  this  point,  some  operators 
considering  that  the  hearing  is  not  further  impaired,  while 
others  believe  that  in  the  large  number  of  cases  tinnitus  is 
not  produced  as  is  sometimes  suggested,  and  the  hearing  is 
to  some  extent  improved.  It  seems  that  in  the  majority  of 
cases,  at  the  most,  it  is  not  rendered  worse,  although  the 
patient  should  always  be  cautioned  previous  to  operation  that 
there  is  a  possibility  of  its  being  greatly  impaired  as  the 
result  of  the  surgical  procedures.  Probably  the  most  light 
upon  this  aspect  of  the  subject  is  given  in  the  studies  of 
Grossmann,  who  in  two  hundred  and  sixteen  cases  of  the 
radical  operation,  found  that  with  an  intact  labyrinth  the 
operation  improved  the  hearing  in  48.5  per  cent.,  especially 
when  the  deafness  had  been  considerable,  while  in  20.2  per 
cent,  there  was  no  alteration  and  in  31.3  per  cent,  it  was 
diminished.  In  49.5  per  cent,  of  the  cases  where  the  tests 
showed  the  full  integrity  of  the  inner  ear  to  be  wanting,  it 
remained  unchanged,  while  in  38.8  per  cent,  of  these  there 
occurred  a  fair  amount  of  improvement  in  the  hearing  and 
in  such  cases  a  diminution  of  hearing  following  the  opera- 
tion and  the  after  treatment  is  most  unlikely,  as  it  occurred 
in  but  15.3  per  cent,  of  the  cases. 

Following  the  dressing  of  the  wound  at  the  time  of  opera- 
tion, which  has  previously  been  described,  it  is  advisable  that 
a  large  bandage  be  used  to  hold  the  dressings  in  place  and 
protect  the  parts,  this  being  especially  requisite  when  the 
cavity  in  the  bone  is  to  be  allowed  to  remain  patulous  for  a 
considerable  period  of  time.  As  the  patient  is  very  apt  to 
disturb  the  outer  dressings  for  the  first  few  hours  after 
operation,  it  is  necessary  that  the  bandage  be  firmly  yet  com- 


After  Treatment  of  Mastoid  Operations.       395 

f ortably  applied,  so  that  the  opposite  ear  remains  uncovered ; 
a  very  satisfactory  bandage  for  this  purpose  being  one  ex- 
tending from  the  front  to  the  back  of  the  head  and  beneath 
the  lower  jaw,  so  that  it  forms  repeated  turns  of  a  figure 
of  eight.  In  very  restless  individuals  or  in  young  children, 
it  will  be  necessary  to  further  secure  the  bandage  for  a  short 
time  with  strips  of  adhesive  plaster,  and  while  some  surgeons 
prefer  the  use  of  a  starch  bandage  for  the  first  dressing  in 
such  cases,  yet  this  is  usually  very  uncomfortable  and  where 
its  stiff  edges  come  in  contact  with  the  skin  it  is  apt  to  pro- 
duce considerable  irritation,  so  that  as  a  rule  it  is  wiser  not 
to  employ  it.  As  the  healing  of  the  wound  progresses  the 
retaining  bandage  may  be  made  still  lighter,  while  in  many 
cases  Koerner's  dressing  will  be  found  most  satisfactory,  as 
it  leaves  the  non-operated  ear  entirely  free  and  makes  no 
pressure  upon  its  upper  portion,  as  is  so  often  done  by  other 
bandages,  it  being  applied  by  first  fixing  the  roller  by  sev- 
eral turns  around  the  forehead  and  occiput  and  then  repeated 
turns  are  taken  over  the  ear,  forehead  and  the  nape  of  the 
neck,  until  the  operated  area  is  entirely  protected.  In  radical 
mastoid  operations  in  general,  the  original  dressing  should 
be  allowed  to  remain  unchanged  for  four  days  to  a  week,  so 
that  granulation  is  well  advanced  and  the  first  dressing  is 
rendered  less  painful,  but  care  should  be  taken  that  it  is 
not  retained  for  too  long  a  period  on  account  of  the  ten- 
dency of  exuberant  granulation  tissue  to  grow  into  the 
meshes  of  the  gauze  packing.  Should  untoward  symptoms 
occur,  however,  such  as  marked  pain,  a  rise  of  temperature 
or  excessive  purulent  secretion,  so  that  the  bandages  become 
saturated,  the  dressings  should  be  changed  at  once,  but  as 
regards  the  temperature,  if  it  does  not  exceed  one  hundred 
degrees  for  three  or  four  days,  or  if  higher  than  this,  is  only 
temporary,  it  is  not  necessary  for  this  reason  alone  to  make 
any  change.  In  many  cases  it  will  prove  advantageous  to 


396  Suppuration  of  the  Middle  Ear. 

remove  the  original  dressings  in  a  shorter  time  than  this,  for 
as  a  rule  there  is  no  necessity  for  retaining  the  first  dressing 
any  longer  than  the  requisite  time  to  allow  the  flap  to  become 
securely  attached  to  the  osseous  walls,  a  period  of  four  or 
five  days  often  being  sufficient  for  this  purpose. 

-  Following  the  original  redressing  and  during  the  course 
of  the  after  treatment,  should  the  wound  run  a  normal  course 
with  rapid  healing  and  a  minimum  amount  of  secretion,  about 
every  three  days  will  be  a  sufficient  time  to  remove  the  gauze 
dressings  and  repack  again,  while  if  the  secretion  be  very 
profuse  they  must  be  changed  daily,  and  under  no  circum- 
stances should  the  dressings  be  allowed  in  such  cases  to 
remain  unchanged  for  more  than  forty-eight  hours.  The 
time  at  which  the  bandages  should  be  entirely  dispensed  with 
will  depend  upon  the  nature  of  the  operation  performed, 
and  will  of  necessity  differ  in  even  every  case  of  the  same 
operation,  this  question  being  decided  entirely  by  the  degree 
of  repair  of  the  parts  and  the  completeness  with  which  the 
cavity  in  the  bone  is  filled  with  healthy  granulation  tissue  in 
the  simple  opening  of  the  mastoid,  or  the  epidermization  of 
the  parts  in  the  more  radical  procedures. 

After  the  simple  mastoid  operation,  it  is  as  a  rule  only 
necessary  to  keep  the  patient  in  bed  a  week  to  ten  days  in 
the  average  case,  but  when  the  radical  operation  has  been 
performed,  especially  if  the  removal  of  the  morbid  tissue  has 
been  at  all  extensive,  the  patient  should  remain  in  bed  for 
at  least  one  week,  and  longer  if  the  dura  or  lateral  sinus 
have  been  exposed,  while  in  those  cases  where  there  are 
evidences  of  even  mild  septicemia  before  operation,  or  where 
the  wound  is  running  an  irregular  course  with  a  rise  in  tem- 
perature, local  pain  or  other  untoward  symptoms,  the  patient 
should  be  confined  to  bed  for  an  indefinite  period,  or  as  long 
as  any  unfavorable  local  or  general  symptoms  are  at  all 
manifested. 


After  Treatment  of  Mastoid  Operations.       397 

It  is  essential  before  each  dressing  that  the  parts  adja- 
cent to  the  wound  should  be  carefully  cleansed  and  ren- 
dered as  aseptic  as  possible  by  any  of  the  methods  familiar 
to  the  surgeon;  a  very  satisfactory  procedure,  however,  for 
this  purpose  being  to  wash  the  parts  with  a  warm  physiologic 
salt  solution  and  then  gently  mop  with  alcohol,  the  advan- 
tages of  this  being  that  the  tissues  may  thus  be  rendered 
thoroughly  clean  and  the  dangers  of  additional  infection 
practically  eliminated,  while  at  the  same  time  no  irritation 
of  the  tissues  around  the  wound  in  the  mastoid  will  result. 
If  desired,  however,  in  cases  where  there  is  a  purulent  dis- 
charge, probably  excessive  in  amount,  a  weak  bichloride  solu- 
tion, boric  acid,  or  salicylic  acid  solutions  may  be  employed 
for  the  same  purpose  by  mopping  over  the  parts  with  a  gauze 
sponge  or  cotton  tuft,  but  in  all  cases  strict  asepsis  during 
this  change  of  dressings  is  essential,  and  as  far  as  possible 
this  should  approach  that  carried  out  during  the  operation 
in  its  thoroughness.  It  is  also  especially  important  that 
the  hands  of  the  surgeon  when  dressing  the  ear  should  be 
thoroughly  cleansed,  and  that  the  instruments,  dressings, 
and  whatever  may  be  brought  into  contact  with  the  ear,  be 
rendered  perfectly  sterile,  it  being  advisable  in  cases  where 
any  pus  still  remains  to  use  separate  forceps  for  removing 
the  gauze  packing  from  the  ear  and  also  for  replacing  it  with 
fresh  sterile  gauze. 

In  the  simple  opening  of  the  antrum  when  the  mastoid 
wound  has  not  been  closed  at  the  time  of  the  operation,  if 
there  be  but  little  discharge  and  that  of  a  serous  character 
at  the  first  removal  of  the  external  dressings  and  the  parts 
are  covered  with  healthy  granulation  tissue  with  absolutely 
no  evidence  of  any  diseased  tissue,  a  local  or  general  anaes- 
thetic may  be  employed,  preferably  the  former,  and  the  mas- 
toid wound  may  be  closed  with  sutures.  This  procedure 
shortens  by  a  considerable  time  the  healing  process  and  the 


398  Suppuration  of  the  Middle  Ear. 

after  treatment,  but  in  the  majority  of  cases  a  certain  risk 
is  necessarily  taken,  as  a  small  area  of  tissue  in  the  cavity 
which  still  remains  may  later  break  down  and  suppurate,  so 
that  it  will  necessitate  the  reopening  of  the  wound.  In  the 
great  majority  of  these  cases,  however,  it  will  be  better  to 
allow  the  wound  to  fill  up  by  granulation  tissue  from  the 
bottom,  and  then  it  is  essential  that  the  passage  between 
the  wound  cavity,  antrum  and  tympanum  be  kept  free  from 
excessive  granulation  tissue  development  which  is  apt  to 
become  exuberant  in  this  space,  as  long  as  the  suppurative 
process  in  the  tympanic  cavity  continues.  To  keep  these 
parts  free  it  may  be  necessary  from  time  to  time  to  curette 
the  granulations  away  at  this  point,  although  as  a  rule,  if  the 
carious  bone  has  been  thoroughly  removed,  this  will  not  be 
found  to  be  necessary.  In  a  considerable  number  of  these 
cases  unhealthy  granulations  are  apt  to  develop  on  the  edges 
of  the  incision  in  the  skin  and  prove  a  serious  annoyance  by 
partially  or  completely  closing  the  entrance  to  the  cavity  in 
the  bone,  and  when  such  a  tendency  is  found  to  be  present, 
one  should  always  thoroughly  curette  the  parts  until  the 
granulations  have  been  entirely  removed. 

While  in  the  radical  operation  the  mastoid  cavity  and  the 
external  auditory  canal  are  thrown  into  one  space,  so  that 
local  treatment  to  one  necessarily  implies  that  the  other  must 
also  at  the  same  time  be  treated,  such  is  not  the  case  in  the 
simple  mastoid  operation,  and  it  is  essential  that  the  tym- 
panic cavity  be  treated  as  may  seem  best  in  the  individual 
case,  at  the  same  time  as  the  treatment  of  the  wound  in  the 
mastoid  process.  When  the  simple  mastoid  operation  is  per- 
formed in  suitable  cases  where  by  this  procedure  the  limited 
amount  of  morbid  tissue  can  be  thoroughly  removed  and  free 
drainage  established,  the  suppuration  rapidly  ceases  and  the 
opening  in  the  mastoid  quickly  fills  with  firm  granulation 
tissue,  so  that  complete  healing  takes  place  within  a  few 
weeks. 


After  Treatment  of  Mastoid  Operations.       399 

After  Stacke's  operation  the  patient  should  be  confined 
to  bed  for  about  a  week  if  the  conditions  are  favorable, 
although  quite  a  number  of  cases  require  absolute  rest  for 
only  four  or  five  days,  when  they  may  then  go  about  as  usual 
except  that  for  some  time  longer  active  exercise  must  not  be 
indulged  in  until  the  wound  has  completely  cicatrized.     In 
the  majority  of  cases  it  becomes  necessary  to  change  the 
outer  dressings  the  day  following  operation,  as  they  are 
usually  saturated  with  blood  stained  serum,  but  the  gauze 
dressing  may  be  allowed  to  remain  for  several  days  longer 
if  no  unfavorable  symptoms  are  present.     At  the  end  of  from 
five  to  eight  days  granulation  tissue  should  be  fairly  well 
developed  and  then  the  first  dressing  may  be  made  by  re- 
moving the  rubber  tube  and  the  gauze  packing  and  replacing 
the  latter  with  fresh  gauze,  as  usually  by  this  time  the  flaps 
are  readily  retained  in  position  and  it  is  not  necessary  to 
replace  the  rubber  tube.     Following  this  in  the  average  case, 
it  is  not  necessary  to  change  the  dressings  of  tener  than  every 
third  or  fourth  day,  while  the  incision  behind  the  ear  usually 
heals  in  from  two  to  three  weeks.     At  any  time  during  the 
course  of  the  after  treatment,  but  more  especially  during  the 
first  week  after  operation,  should  the  temperature  rise  and 
continue  high,  the  dressings  should  be  removed  and  the  cause 
of  the  fever  sought,  as  a  rule  the  most  common  causes  being 
small  pus  collections  in  the  cavity,  or  under  the  subcutaneous 
tissue  or  periosteum  in  the  neighborhood  of  the  mastoid 
wound.     As  a  rule  when  the  secondary  pus  collections  are 
found  they  are  usually  present  near  the  upper  portion  of  the 
incision  and  if  such  a  condition  is  found  here  and  the  pus 
evacuated  with  the  temperature  still  remaining  above  normal, 
more  thorough  search  should  be  made  in  the  deeper  portions 
of  the  osseous  cavity  and  especially  in  the  neighborhood  of  the 
sigmoid  fossa  or  in  the  vicinity  of  the  antrum.     It  should 
be  remembered,  however,  that  in  occasional  cases  after  the 


400  Suppuration  of  the  Middle  Ear. 

Stacke  or  any  other  operation,  a  post-operative  temperature 
may  result  from  some  general  disease  also  present,  or  from 
local  trouble  elsewhere  in  the  body  and  may  bear  no  relation 
at  all  to  the  mastoid  wound  which  careful  examination  shows 
is  running  a  perfectly  normal  course. 

The  care  of  the  patient  upon  whom  a  Stacke-Schwartze 
Or  other  similar  radical  operation  has  been  performed,  is 
identical  in  many  respects  with  that  described  previously,  the 
dressings  being  varied  somewhat,  dependent  upon  whether 
the  retro-auricular  opening  is  to  be  closed  immediately  by 
primary  union,  later  by  granulation,  or  is  to  be  permanently 
maintained  as  an  open  fistula.  In  the  few  cases  where 
primary  union  may  be  effected,  great  care  must  be  taken  in 
concluding  the  operation  that  all  morbid  tissue  above  and 
behind  the  antrum  should  be  most  thoroughly  removed,  as 
in  the  subsequent  healing  of  the  parts  these  are  usually  the 
last  to  be  protected  by  firm  epithelium,  and  it  will  often  be 
found  that  even  after  the  cavity  has  been  tamponed  for  sev- 
eral months  these  parts  will  continue  to  show  some  granu- 
lation growth  and  purulent  discharge,  often  for  a  long  time 
after  other  parts  of  the  cavity  have  undergone  resolution. 
In  addition  to  firm  packing  to  overcome  this,  it  will  often 
become  necessary  to  gently  curette  this  area  through  the 
widened  canal,  and  from  time  to  time,  if  the  granulation 
tissue  becomes  excessive,  it  may  also  be  cauterized,  while  it 
is  very  essential  that  free  drainage  be  constantly  maintained. 
After  the  radical  operation  in  the  case  free  from  untoward 
symptoms,  the  first  dressing  should  not  be  changed  before 
the  seventh  or  eighth  day,  and  if  skin  grafts  have  been 
placed  on  the  walls  of  the  cavity,  as  previously  described 
after  the  method  recommended  by  Bench,  the  entire  cuta- 
neous wound  will  be  found  to  have  united.  At  the  end  of 
this  time  in  such  cases  the  gauze  strip  and  cotton  pledgets 
are  removed  from  the  canal.  The  canal  is  then  lightly  dusted 


After  Treatment  of  Mastoid  Operations.       401 

with  aristol,  the  meatus  is  loosely  packed  with  gauze  and  a 
light  antiseptic  external  dressing  is  applied  over  all  the  parts. 
After  this  the  dressings  should  be  changed  about  every 
second  day. 

When  this  method  of  skin  grafting  is  not  adopted  and 
the  wound  is  normal,  the  method  of  tamponing  the  cavity 
varies,  usually  after  the  third  week,  as  determined  whether 
secondary  closure  of  the  mastoid  wound  is  to  be  effected  or 
a  persistent  retro-auricular  opening  is  to  remain.  If  the 
latter  is  desired,  the  tampon  should  be  applied  to  the  cavity 
through  the  mastoid  opening  until  the  epidermis  lining  the 
interior  of  the  cavity  has  become  continuous  with  that  cov- 
ering the  external  surface  of  the  mastoid  process,  when  prac- 
tically a  single  skin  surface  exists  over  the  entire  region 
here,  while  in  those  cases  where  it  is  desired  to  obtain  sec- 
ondary closure  after  the  suppuration  has  greatly  diminished 
in  amount  or  ceased  entirely,  usually  after  the  third  to  fifth 
week,  the  cavity  should  then  be  packed  by  way  of  the  external 
auditory  canal,  and  if  this  be  inaugurated  before  the  epi- 
thelial surfaces  of  the  interior  of  the  cavity  have  come  into 
communication  with  the  external  skin  surfaces,  the  cavity 
will  gradually  diminish  in  size  and  finally  close  completely, 
so  that  but  a  slight  cicatrix  will  remain.  In  all  these  cases 
where  cholesteatoma  has  been  removed,  one  is  very  apt  to 
find  an  excessive  proliferation  of  epithelium  forming  well 
up  in  a  posterior  and  superior  recess  of  the  osseous  cavity 
after  the  walls  have  become  fairly  well  covered  with  a  firm 
epithelial  layer ;  under  these  circumstances  the  deposit  at  this 
point  should  be  removed  as  soon  as  it  forms  and  the  recess 
must  be  lightly  tamponed  with  gauze,  so  that  it  may  become 
obliterated  with  healthy  granulation  tissue.  It  is  essential 
in  any  mastoid  operation  for  chronic  otorrhcea  that  thorough 
drainage  be  maintained  as  long  as  any  secretions  are  present 
in  any  part  of  the  wound  cavity  and  only  when  one  is  sure 

27 


402  Suppuration  of  the  Middle  Ear. 

that  the  suppuration,  especially  in  the  deeper  parts  of  the 
wound,  has  entirely  ceased,  may  the  drainage,  either  by 
means  of  rubber  tube  or  gauze  be  removed.  Under  no  cir- 
cumstances, therefore,  should  the  posterior  wound  be  allowed 
to  heal  while  suppuration  in  any  degree  continues,  and  the 
communication  between  the  deeper  parts  of  the  tympanic 
cavity  and  other  portions  of  the  wound  in  the  bone  should 
be  kept  free  by  constant  drainage. 

As  an  aid  to  drainage,  if  the  purulent  discharge  be  very 
profuse,  irrigations  may  be  employed  each  time  the  dressings 
are  changed,  the  solution  employed  being  allowed  to  flow 
from  the  opening  behind  the  ear  out  through  the  external 
auditory  canal,  but  if  there  be  not  much  secretion  present 
it  is  better  as  a  rule  to  avoid  the  use  of  irrigations.  At  the 
first  dressing,  however,  irrigation  is  not  only  of  decided 
value,  but  is  often  necessary  in  order  to  remove  the  gauze 
tampons  which  have  become  adherent  to  the  raw  surfaces 
and  produce  a  great  deal  of  pain  in  their  removal;  in  addi- 
tion to  this  the  irrigation  is  of  service,  as  the  flaps  made 
from  the  membraneous  canal  tube  are  not  always  firmly 
adherent  to  the  underlying  tissues,  and  unless  the  dressings 
are  thus  loosened  in  this  manner  they  are  very  apt  to  adhere 
to  the  flaps  in  part  and  tear  them  away.  After  this,  how- 
ever, in  the  majority  of  cases  subsequent  irrigations  are  un- 
necessary, unless  they  be  indicated  by  the  presence  of  such 
untoward  signs  as  pain,  fever  or  other  septic  symptoms, 
when  a  two  or  three  per  cent,  solution  of  lysol  may  be  used, 
or  a  weak  bichloride  or  diluted  peroxide  of  hydrogen  solu- 
tion may  be  employed  for  the  same  purpose.  When  for  any 
reason  it  is  desired  to  irrigate,  and  some  surgeons  employ 
irrigation  in  nearly  all  cases,  in  such  cases  where  the  secre- 
tions are  not  excessively  profuse  or  offensive,  the  most  satis- 
factory solution  for  this  purpose  is  warm  sterile  water, 
or  if  this  it  not  desired,  a  physiological  salt  solution  will  be 
found  serviceable. 


After  Treatment  of  Mastoid  Operations.       403 

After  the  radical  operation,  great  care  must  be  exercised 
in  the  conduct  of  the  after  treatment  relative  to  the  develop- 
ment of  granulation  tissue,  as  it  is  desired  that  the  osseous 
cavity  should  not  heal  by  becoming  filled  with  granulations, 
but  that  they  should  form  a  firm  surface  over  its  entire  walls 
in  order  to  act  as  an  efficient  basis  for  the  development  of 
the  epithelial  covering.  In  order  to  accomplish  this  result 
it  is  necessary  that  an  antiseptic  condition  of  the  wound  be 
maintained  and  exuberant  granulation  growth  prevented. 
This  latter  can  be  accomplished  to  a  great  extent  by  firmly 
packing  the  entire  cavity  with  gauze,  so  that  every  crevice 
or  corner  is  also  protected  in  this  manner,  usually  aristol  or 
plain  sterile  gauze  being  most  preferable  for  this  purpose. 
Should  the  packing  be  too  tight,  the  development  of  a  proper 
granulating  surface  will  be  prevented  or  inhibited,  and  should 
this  be  the  case,  as  a  rule,  the  walls  of  the  cavity  will  show 
only  a  slight  inclination  towards  granulation,  so  that  it  will  be 
necessary  to  pack  very  loosely  until  an  even  granulating  sur- 
face has  developed.  Excessive  growth  of  this  tissue  may  also 
be  controlled  by  keeping  the  parts  as  dry  as  possible,  removing 
the  secretion  with  gauze  mops  instead  of  irrigating  and  pack- 
ing every  day,  while  cauterization  of  patches  of  exuberant 
development  here  and  there  may  be  occasionally  required, 
chromic  or  trichloracetic  acid  being  very  useful  for  this  pur- 
pose. If  it  becomes  necessary  to  cauterize  a  large  area,  the 
use  of  chromic  acid  will  not  be  advisable,  but  whatever  may 
be  employed  should  be  preceded  by  the  cocainization  of  the 
tissues  and  the  cauterization  should  be  repeated  at  intervals 
of  several  days,  until  a  healthy  surface  has  been  obtained. 
In  another  class  of  cases,  where  the  development  is  still  more 
excessive,  so  that  cauterization  will  not  be  sufficient  to  con- 
trol them,  it  may  become  necessary  to  curette  the  parts  occa- 
sionally, when  the  proliferating  granulations  should  be  thor- 
oughly scraped  away.  In  occasional  cases  one  will  find  that 


404  Suppuration  of  the  Middle  Ear. 

particular  attention  will  have  to  be  directed  to  the  region  of 
the  horizontal  semicircular  canal  and  facial  spur  which  re- 
mains after  the  radical  operation,  as  between  these  parts  and 
the  roof  of  the  tympanum  there  is  but  a  comparatively  small 
space  after  the  granulations  have  fully  formed,  and  if  they 
are  not  controlled  here  both  surfaces  are  very  apt  to  grow 
together  and  strong  connective  tissue  bands  may  later  de- 
velop which  cause  partial  occlusion  of  the  epitympanic  space 
and  the  antrum,  the  final  result  being  that  the  antrum  is  in 
communication  with  the  tympanum  proper  only  by  means  of 
a  small  opening  in  this  septum,  so  that  a  small  pocket  is 
formed  in  this  region,  producing  a  continuation  of  the  sup- 
puration by  constantly  reinfecting  the  tissues  from  the 
caseous  pus  which  is  apt  to  become  lodged  here.  As  healing 
progresses  normally,  the  granulating  surface,  instead  of 
being  irregular,  becomes  smoother  and  paler  in  color,  and 
epidermization  progresses,  which  may  be  aided  by  the  in- 
sufflation of  various  antiseptic  powders,  such  as  aristol,  boric 
acid,  etc. 

As  it  is  necessary  that  the  mouth  of  the  Eustachian  tube 
be  kept  sealed  in  order  to  avoid  additional  infection  from  the 
nasopharynx,  it  should  be  well  tamponed  when  dressing  the 
cavity  immediately  after  operation  and  during  the  after  treat- 
ment this  should  be  applied  at  each  dressing  until  the  desired 
result  has  been  obtained.  If  this  closure  is  not  soon  accom- 
plished as  the  result  of  the  previous  curetting  away  of  its 
mucosa  of  the  tympanic  mouth,  it  may  be  closed  during  the 
process  of  healing  of  the  mastoid  wound  by  cauterization, 
the  galvanocautery  point  lightly  touched  to  the  parts  usually 
being  sufficient  to  form  the  desired  barrier  at  this  point. 
Should  epidermization  be  defective  in  limited  areas,  or  after 
newly  developed  necrosed  tissue  has  from  time  to  time  been 
removed,  it  may  be  advisable  to  place  small  skin  grafts  over 
such  parts  in  order  to  hasten  resolution  and  produce  cessa- 


After  Treatment  of  Mastoid  Operations.       405 

tion  of  the  suppuration.  Small  grafts  are  sufficient  for  this 
purpose  and  they  are  applied  in  the  same  manner  as  when 
employed  at  the  time  of  operation,  the  bleeding  which  some- 
times takes  place  from  adjoining  granulation  tissue  when 
they  are  placed  in  the  cavity  being  effectually  controlled  with 
adrenalin,  which  renders  the  secondary  grafting  a  matter  of 
but  little  time,  and  while  it  controls  any  reactive  oozing, 
which  is  otherwise  apt  to  take  place,  it  is  perfectly  harmless 
to  the  delicate  graft  itself.  After  these  small  pieces  of 
dermal  tissue  have  been  placed  in  the  desired  positions,  they 
are  carefully  protected  by  small  pieces  of  gauze.  Gold  leaf 
or  sterilized  tin  foil  may  be  used  to  prevent  the  adhesion  of 
the  grafts  to  the  packing.  Should  it  become  necessary  to 
apply  such  a  graft  to  the  region  of  the  stapes  or  oval  window 
either  at  the  time  of  operation  or  during  the  course  of  the 
after  treatment,  one  should  be  careful  to  avoid  placing  it 
directly  over  these  parts,  as  it  is  very  apt  to  seriously  impair 
the  hearing  and  this  will  not  only  take  place  at  the  time  the 
graft  is  placed  here  to  some  extent,  but  the  hearing  will 
become  much  worse  as  time  goes  on  if  the  graft  is  successful 
from  the  epidermis  in  this  location  becoming  very  much 
thicker. 

The  epidermization  of  the  cavity  after  the  radical  opera- 
tion usually  takes  a  considerable  time  and  requires  a  great 
deal  of  care  and  attention  for  three  to  six  months,  or  even 
longer  in  some  cases.  The  tampon  must  be  kept  up,  how- 
ever, until  the  walls  have  been  well  covered  by  the  growing 
epithelium  and  especially  must  the  gauze  packing  be  em- 
ployed when  adjacent  parts  are  granulating,  for  if  they  be 
allowed  to  come  in  contact  before  a  dry  epithelial  surface 
has  formed  at  least  on  one  of  the  opposing  parts,  adhesions 
will  inevitably  form  and  cause  pus  retention.  After  the  sur- 
faces have  become  fairly  well  covered  with  epithelium,  the 
tampons  can  be  omitted  from  time  to  time,  or  permanently  in 


406  Suppuration  of  the  Middle  Ear. 

some  cases,  as  the  exposure  to  the  air  greatly  aids  in  the 
progress  of  healing,  and  as  previously  mentioned,  this  may 
also  be  accelerated  by  the  use  of  a  nonirritating  antiseptic 
powder  at  this  time,  especially  as  such  a  measure  greatly  pro- 
tects the  immature  epithelial  cells  from  maceration  by  the 
secretions.  Should  grafting  be  successful  at  first  and  the 
mastoid  wound  be  small,  epidermization  may  be  completed  in 
six  or  eight  weeks,  but  when  the  wound  is  very  large  this 
occupies  a  much  longer  period  and  it  may  be  a  number  of 
months  before  the  parts  have  entirely  become  covered.  The 
first  appearance  of  successful  epidermization  is  shown  by 
the  extension  over  the  granulating  surfaces  of  delicate  white 
areas  from  the  epithelial  grafts  and  thus  producing  an  in- 
crease in  extent  of  these  grafts.  When  the  condition  be- 
comes well  marked,  it  is  better  to  discontinue  the  use  of 
iodoform  gauze,  if  such  has  been  employed,  and  substitute 
for  it  either  plain  or  aristol  gauze,  as  being  less  liable  to  pro- 
duce irritation  and  harm  to  the  delicate  epithelial  surface.  It 
is  only  necessary  at  this  stage  of  healing  to  tampon  the  cavity 
every  other  day,  and  if  after  a  time  the  skin  growth  sloughs 
away  in  part,  or  lack  vitality  for  further  proliferation,  the 
cavity  should  be  carefully  cleansed  with  sterile  physiological 
salt  solution  and  new  Thiersch  grafts  applied  without  again 
tamponing,  but  merely  protecting  the  field  with  a  light  gauze 
and  cotton  external  dressing. 

Burnett  believes  that  after  the  radical  operation,  the  sub- 
sequent treatment  should  aim  towards  carnification  rather 
than  dermization  of  the  newly  formed  middle  ear  cavity,  and 
that  this  process  is  to  be  conducted  by  way  of  the  external 
auditory  meatus.  As  the  drum  cavity,  aditus  and  antrum 
are  mucus  lined,  the  process  of  nature  in  healing  indicates 
the  advisability  of  trying  to  carnify  the  mucous  lining  after 
the  resection  of  the  carious  bone  from  these  regions,  rather 
than  endeavoring  to  line  it  with  a  true  skin;  skin  in  such  a 


After  Treatment  of  Mastoid  Operations.       407 

cavity  being  heterotopic  and  observation  shows  that  nature 
does  not  adopt  this  method  of  healing  a  suppurating  ear. 
He  further  states  that  in  general  it  may  be  said  that  true 
skin  is  out  of  place  in  a  closed  cavity  like  the  mastoid,  there- 
fore as  regards  the  after  treatment  of  cholesteatoma,  it  ap- 
pears more  rational  to  thoroughly  remove  the  heterologous 
mass  and  heal  the  wound  cavity  from  the  bottom  without  a 
retro-auricular  opening. 

Whenever  osseous  tissue  is  removed  from  the  mastoid, 
the  cavity  thus  formed  should  be  packed  with  gauze  in  pref- 
erence to  any  other  material,  iodoform  gauze  being  usually 
employed  at  first  and  afterward  replaced  with  sterile  gauze 
should  the  former  produce  irritation  or  actual  eczema,  or  if 
excessive  granulation  tissue  growth  takes  place,  as  iodoform 
favors  the  exuberant  proliferation  of  granulations.  Subse- 
quent dressings,  as  regards  the  packing  of  the  cavity,  should 
usually  be  carried  out  the  same  as  the  first  dressing,  but  it  is 
very  necessary  that  the  osseous  wound  should  be  firmly 
packed,  as,  if  this  is  not  carefully  carried  out,  favorable 
results  will  be  materially  delayed.  Should  the  dura  or  lateral 
sinus  be  exposed  during  the  course  of  the  operation,  the  pack- 
ing from  the  rest  of  the  cavity  not  in  relation  with  these 
exposed  parts  should  be  first  removed,  and  then  with  the 
most  scrupulous  aseptic  precautions,  the  gauze  pads  can  be 
taken  away  from  the  dangerous  areas  and  the  parts  cleared 
of  secretion  by  gentle  mopping  with  sterile  gauze.  After  the 
cavity  has  been  cleansed  in  this  manner,  these  areas  should 
first  be  protected  at  each  dressing  and  a  separate  piece  of 
gauze  used  to  cover  them,  after  which  the  rest  of  the  cavity 
is  given  the  usual  attention.  When  the  opening  behind  the 
auricle  has  healed  to  such  an  extent  that  it  is  desirable  to 
allow  it  to  close,  the  method  of  packing  should  be  changed, 
so  that  a  gradual  attempt  should  be  made  to  pack  the  osseous 
cavity  by  way  of  the  external  osseous  canal,  so  that  the  soft 


4o8  Suppuration  of  the  Middle  Ear. 

parts  over  the  mastoid  may  come  together  and  unite.  Should 
this  be  accomplished  gradually,  the  depression  of  the  cavity 
becomes  filled  out  and  a  fairly  smooth  surface  results  with 
but  little  disfigurement,  but  when  this  cannot  be  brought 
about,  a  permanent  posterior  opening  remains  or  more  fre- 
quently a  deep  hollow  is  formed  which  slowly  becomes 
cicatrized. 

Should  one  or  more  small  fistulous  openings  persist  in 
connection  with  the  mastoid  incision  after  it  has  healed  along 
the  greater  part  of  its  length,  but  which  do  not  communicate 
with  a  bone  sinus  in  any  way,  they  may  usually  be  healed 
by  cauterizing  the  edges  with  strong  nitrate  of  silver  or  tri- 
chloracetic  acid,  while  in  a  certain  small  proportion  of  such 
cases  where  these  measures  prove  ineffectual,  the  edges  of 
the  fistula  should  be  lightly  seared  with  the  galvano-cautery, 
after  which  healing  is  usually  prompt. 

Where  the  radical  operation  has  been  performed,  the 
patient  should  be  advised  in  advance  of  the  tediousness  of 
the  after  treatment,  as  in  the  cases  which  run  the  usual 
favorable  course,  the  average  time  for  epidermization  to  take 
place  is  from  three  to  four  months,  while  in  many  instances 
five  or  six  months  or  more  elapse  before  the  middle  ear  cavi- 
ties are  perfectly  dry  and  free  from  secretion.  In  the  simple 
mastoid  operation  the  usual  time  required  for  the  process  of 
healing  is  of  course  much  shortened,  being  from  four  to  six 
weeks  as  an  average,  and  during  this  period  the  growth  of 
healthy  granulations  which  takes  place,  gradually  makes  the 
osseous  cavity  much  smaller  and  finally  completely  obliter- 
ates it,  the  external  wound  in  such  cases  finally  healing  by 
a  linear  cutaneous  scar,  or  there  may  be  a  somewhat  de- 
pressed bony  cicatrix,  to  which  the  overlying  cutaneous  tissue 
is  intimately  adherent. 

During  the  after  treatment,  various  unfavorable  local 
symptoms  may  occur  from  time  to  time  and  retard  the  process 


After  Treatment  of  Mastoid  Operations.       409 

of  repair  in  the  tissues,  the  most  important  of  these  being 
an  excessive  discharge  of  pus  from  the  cavity,  soaking  en- 
tirely through  the  dressings.  This  is  usually  the  result  of 
some  carious  tissue  which  has  not  been  completely  removed, 
or,  as  may  be  shown  by  the  probe,  proceeds  from  a  small 
pocket  filled  with  purulent  material  which  has  been  previously 
undiscovered.  If  a  softened  area  of  bone  should  at  any  time 
be  thus  found,  or  if  any  roughness  of  the  walls  of  the  cavity 
is  present  it  should  be  thoroughly  scraped  away  with  the 
curette,  cleansed  with  the  usual  antiseptic  solutions  or  pref- 
erably peroxide  of  hydrogen  and  the  cavity  packed  with 
gauze  as  before.  At  a  much  later  stage,  the  development 
of  eczema  may  cause  considerable  annoyance,  but  as  a  rule 
this  is  usually  due  in  susceptible  individuals  to  the  iodoform 
gauze  which  is  employed,  and  disappears  upon  its  withdrawal, 
If  this  irritation  of  the  skin  surrounding  the  wound  and  also 
involving  the  auricle  be  present,  aristol  or  plain  sterile  gauze 
should  be  substituted  and  the  parts  may  be  dusted  with  aristol, 
boric  acid  or  an  ointment  of  yellow  oxide  of  mercury  may  be 
very  successfully  employed,  while  if  at  the  same  time  the  pur- 
ulent discharge  is  profuse,  the  surrounding  tissues  should  be 
protected  either  with  lanolin  or  with  the  mercurial  ointment 
mentioned.  After  epidermization  has  been  completed,  it  is  not 
unusual  to  find  in  the  vicinity  of  the  antrum  or  in  any  recesses 
of  the  cavity  the  formation  of  scales  of  epidermis  scales  or 
small  crusts,  which  are  apt  to  be  productive  of  at  the  least 
considerable  annoyance  and  more  frequently  of  a  relapse  of 
the  aural  suppuration.  To  avoid  this  as  far  as  possible,  the 
patient  should  be  looked  after  and  the  cavity  cleansed  by  the 
physician  every  month  or  more  until  this  tendency  has  been 
entirely  removed,  while  if  the  condition  be  present,  even 
though  slight,  the  patient  may  at  home  instil  alcohol  or  a 
solution  of  boric  acid  in  alcohol  into  the  ear  once  or  twice 
a  week,  after  previously  removing  the  epithelial  debris  and 


410  Suppuration  of  the  Middle  Ear. 

crusts  with  peroxide  of  hydrogen.  Some  few  cases  rapidly 
cease  when  the  ear  is  washed  with  a  physiological  salt  solu- 
tion every  week  or  so,  depending  upon  the  necessities  of  the 
particular  case,  while  in  others  a  small  area  of  suppuration 
not  involving  the  osseous  tissue  remains,  which  should  be 
treated  in  the  usual  manner. 

In  a  very  few  cases  after  radical  operation  and  during 
the  first  or  second  week  of  the  after  treatment,  an  untoward 
feature  of  considerable  importance  is  the  appearance  of  a 
facial  paresis.  When  this  occurs  only  after  the  first  dress- 
ing, it  is  usually  the  result  of  pressure  or  some  slight  inflam- 
matory irritation  of  the  facial  nerve  and  in  practically  all 
cases  disappears  after  a  few  weeks  without  any  special  treat- 
ment being  indicated.  Finally,  among  the  untoward  phe- 
nomena, is  the  elevated  temperature  which  often  occurs  after 
mastoid  operations.  It  is  often  a  most  difficult  matter  to 
ascertain  its  cause  and  in  a  recent  study  by  Harris  of  this 
problem  the  question  in  the  individual  case  in  which  there 
is  a  rise  of  temperature,  is  whether  it  suggests  an  incomplete 
operation  with  retained  pus  or  diseased  bone,  or  imperfect 
asepsis,  or  whether  there  is  a  normally  elevated  post-opera- 
tive temperature  due  to  causes  which  originally  produced  it. 
The  conclusions  in  this  respect,  which  he  derived  from  a 
number  of  cases,  are  that  a  post-operative  temperature  of 
moderate  amount  is  customary  in  mastoiditis;  its  cause  is 
not  known  and  without  accompanying  symptoms  it  means 
nothing.  In  such  cases,  therefore,  the  rise  of  temperature, 
as  described,  requires  no  treatment,  but  in  those  cases  where 
it  is  unduly  continuous  or  elevated,  the  proper  treatment  is 
obvious  after  its  cause  has  been  ascertained. 


INDEX. 


INDEX. 


Abscess,  acute  mastoid,  239 

Aditus,  length  of  the,  182;  relation 
of,  to  the  attic  and  tympanum,  20,  24, 
plate  III 

Adhesions,  between  the  membrana 
tympani  and  the  inner  tympanic 
wall,  14,  106;  cutting  away,  when 
removing  the  ossicles,  112;  surgical 
treatment  of,  in  the  membrana 
tympani,  44 

Adrenalin  chloride  as  a  haemostatic, 
104;  in  ossiculectomy,  102 

After  treatment  of  the  mastoid  opera- 
tions, 393-410 

Alcohol,  for  lessening  the  secretion 
from  granulation  tissue,  161 

Alderton's  method  of  searching  for 
the  incus,  123 

Amberg's  signs  for  indicating  the  dis- 
placement of  the  lateral  sinus,  223, 
224 

Anaesthesia,  general,  for  nervous  or 
restless  patients,  39;  in  mastoid  op- 
erations, 386,  387;  in  opening  the 
attic,  146 ;  local,  Schleich's  method  of, 
in  mastoid  operations,  243;  posture 


of  the  patient  during,  103;  the  ques- 
tion of,  in  ossiculectomy,  103 

Anatomical  and  surgical  landmarks, 
181-226;  landmarks  within  the  mid- 
dle ear  relating  to  diagnosis,  8;  as 
related  to  the  surgical  pathology  of 
the  middle  ear,  10 

Anatomical,  plate  showing  inner  sur- 
face of  the  temporal  bone,  198;  sec- 
tion, of  the  drum  membrane  and 
osseous  auditory  canal,  plate  II,  16; 
of  facial  nerve,  ossicles,  attic  and 
cerebral  fossa,  plate  I,  12;  showing 
auditory  canal  as  seen  from  in  front 
and  above,  plate  III,  24;  showing 
facial  nerve  and  foot  plate  of  the 
stapes,  also  the  Eustachian  tube, 
plate  IV,  28;  through  the  temporal 
bone  exposing  the  inner  surface  of 
the  membrana  tympani  and  ossicles, 
plate  XXV,  220 

Annulus  tympanicus,  plate  XXII,  204 

Antrum,  as  a  "  drip  cup,"  237 ;  avoid- 
ing wounding  the  dura  mater  when 
entering  the,  270;  Broca's  statements 
relative  to  the  depth  of  the,  199; 
care  in  curetting  the,  268;  caries  of 


413 


414 


Index. 


the,  96;  caries  of  the  roof  of  the,  18; 
certainty  that  the,  has  been  opened 
before  curetting  the  mastoid  cells, 
264;  cholesteatoma  of  the,  260;  con- 
dition of  the,  in  chronic  otorrhcea, 
305 ;  depth  of  the,  199,  200 ;  distance 
of  the,  from  the  cortex,  264 ;  entering 
the,  using  the  spine  of  Henle  as  a 
guide  in,  225;  external  wall  of  the, 
difference  of  opinion  as  to  the  depth, 
267;  in  children,  267;  infection  of 
the,  182;  locating  the,  mechanical  de- 
vices for,  251 ;  location  of  the,  186, 
251 ;  location  of  the,  as  a  basis  for 
removing  diseased  tissue,  182;  meas- 
urements of  Holmes  relative  to  the 
depth  of  the,  199;  method  of  opening 
the,  without  breaking  down  the  pos- 
terior canal  wall,  297 ;  opening  of  the, 
as  a  primary  procedure,  239 ;  opening, 
of  the,  at  the  initial  point,  191,  192, 
253>  guiding  rule  for  avoiding  the 
lateral  sinus  in  opening  the,  260; 
relations  of  the,  with  the  aditus  and 
attic,  186;  searching  for  the,  265; 
size  of  the,  185;  statements  of  Ker- 
rison  relative  to  the  depth  of  the, 
199,  200;  topography  of  the,  185; 
variation  as  to  the  depth  of  the,  199; 
various  guides  for  opening  the,  192, 
193;  Zaufal-Kuster  method  of  open- 
ing the,  328 

Aquseductus  Fallopii,  plate  I,  12,  plate 
XX,  194 

Attic,  and  ossicles,  plate  I,  12;  caries 
of  the,  86;  hyperplastic  changes  in 
the,  22;  morbid  changes  in  the,  22; 
relations  of  the,  and  its  walls,  189; 
relations  of  the,  to  the  tympanum 
proper  and  to  the  aditus  and  antrum, 
20,  24,  plate  III ;  suppuration  of  the, 
involving  the  antrum  and  mastoid, 
22;  suppuration  of,  involving  the 
malleus  and  the  incus,  22;  removal 
of  the  incus  for  suppuration  of  the, 
117;  removal  of  the  outer  wall  of 
the,  142,  143;  removal  of,  with  the 
cylindrical  burr,  145,  146 


Atticitis,  external,  144 

Audition    better    where    the    posterior 

wound   heals   from  the   bottom,  327 
Audition,   care  in  grafting  to  prevent 

impairment  of,  405 
Auricle,  attachments  of  the,  225,  226 

B 

Ballance's  mastoid  operation,  333; 
technique  of,  334,  335,  336 

Bergmann's  modification  of  the  mas- 
toid operation,  331,  333 

Biehl's  method,  329 

Blake's  method  for  healing  the  wound 
after  mastoid  operation,  274 

Bleeding,  see  HEMORRHAGE. 

Blood  clot  method  (Blake)  of  closing 
the  wound  after  mastoid  operations, 
274 

Bone,  amount  of,  removed  by  the  cu- 
rette in  radical  operation,  306,  307; 
destruction  of,  and  danger  of  in- 
fection in  opening  up  diploetic  tis- 
sue, 271 ;  diseased,  in  tympanic  walls, 
6  (see  also  under  CARIES)  ;  surfaces, 
covering  the,  with  flaps  after  radical 
operation,  308,  309,  310;  surfaces, 
newly  formed,  epidermal  covering 
of  the,  307,  308,  309;  temporal,  plate 
XX,  194;  pathological  changes  in 
the  temporal,  in  mastoiditis,  281 

Broca,  statement  of,  as  to  the  depth 
of  the  antrum,  199 

Buck,  mastoid  hook  of,  for  locating 
the  antrum,  251 

Burr,  electric,  advantages  of  the,  in 
opening  the  mastoid  cortex,  271 ; 
cooling  of  the,  to  avoid  necrosis,  321 ; 
for  leveling  down  the  facial  spur, 
320;  use  of,  for  grinding  down  os- 
seous tissue,  319,  320 


Calcification  of  the  ossicles,  101 
Canal,     external     auditory,     antiseptic 
measures  a  necessity  in  after  treat- 
ment of  operations  on  the,  159;  caries 
and  necrosis  of  the,  26;  stricture  of 


Index. 


the,  leading  to  pus  retention,  281 ; 
cocaine  anaesthesia  of  the,  38;  de- 
fects of  osseous  continuity  of  the 
upper  wall  of  the,  14,  15;  depth  of 
the,  26;  object  of  operative  pro- 
cedures by  way  of  the,  5,  6;  opera- 
tions through  the,  151-176;  plate  I, 
12;  preparing  the,  for  operation,  36, 
37;  external  semicircular  and  Fal- 
lopian, considered  in  relation  to  aural 
suppuration,  200,  201 ;  protecting  the, 
in  mastoid  operation,  314;  horizontal 
semicircular,  position  of  the,  207; 
semicircular,  course  of  the,  200,  201 ; 
semicircular,  plate  XXI,  198;  wall, 
postero-superior,  length  of,  in  esti- 
mating depth  of  the  Fallopian  and 
horizontal  semicircular,  196,  197;  re- 
moving the  posterior  canal  wall  with 
chisel,  gouge  and  cutting  forceps, 
301 

Caries,  and  necrosis  of  the  pneumatic 
spaces,  260;  local  anaesthesia  in  ex- 
ploring for,  in  the  external  auditory 
canal,  26;  of  the  antrum  associated 
with  cholesteatoma,  96;  of  the  attic 
walls,  17,  86;  of  the  external  audi- 
tory canal,  26;  of  the  handle  of  the 
malleus,  plate  XI,  76;  of  the  head 
of  the  incus,  plate  XII,  90;  of  the 
head  of  the  malleus,  18;  of  the 
incus,  18,  22  86,  90;  of  the  mal- 
leus, 22,  86,  90;  of  the  middle  ear, 
18;  of  the  tip  of  the  manubrium,  17; 
of  the  tympanic  walls,  6 ;  of  the  walls 
of  the  antrum,  260;  use  of  the  elec- 
tric burr  for  removing,  321 
Carious  changes,  knowledge  of,  im- 
portant in  selecting  form  of  opera- 
tion, 98 

Carnification  by  way  of  external  audi- 
tory meatus  after  radical  operation, 
406 

Carotid  artery,  internal,  plate  XX,  194 
Catarrhal   changes    in   the    Eustachian 

tube,  17,  28,  plate  IV 
Cauterization,  of  the  edges  of  fistulous 
openings  after  partial  healing  of  the 


mastoid  incision,  408;  of  the  mucosa, 
55 ;  of  the  tissues  of  the  tympanic 
cavity,  65,  66 

Cell  groupings,  nature  of,  in  relation 
to  important  structures,  190,  191 

Cell  infiltration,  53,  54 

Cells,  aberrant,  in  the  mastoid  process, 
212,  213;  endothelial,  origin  of,  77; 
mastoid,  plate  1, 12 ;  cholesteatoma  of 
the,  260;  hypertrophy  of,  260;  pet- 
rous, 212;  squamous,  211;  pneu- 
matic, of  the  mastoid  process,  211, 
214,  plate  XXIV;  pus,  encapsula- 
tion of,  14 

Channel  operation,  double,  320;  single, 
320 

Chisel,  use  of,  in  removing  bone  in 
mastoid  operations,  254 

Cholesteatoma,  after  treatment  of 
(when  removed  through  the  canal), 
165-168;  formation  of,  327;  most 
frequent  sites  of,  78;  of  the  an- 
trum and  mastoid  cells,  260;  retro- 
auricular  opening  not  desirable  in, 
385,  386;  skin  transplantation  to  pre- 
vent formation  of,  327;  Stacke  oper- 
ation for,  288,  299;  surgical  treat- 
ment of,  79 ;  two  groups  of,  74,  77 

Chromic  acid  in  treatment  of  base  of 
polypi  after  their  removal,  160,  161 

Cocaine,  as  a  local  anaesthetic,  38;  and 
adrenalin  chloride,  as  a  local  anaes- 
thetic in  ossiculectomy,  102 

Completed  simple  mastoid  operation 
(Schwartze)  on  a  bone  specimen, 
plate  XXIX,  266 

Complete  radical  operation  (Stacke- 
Schwartze)  on  a  bone,  plate  XXX, 
284 ;  Stacke-Schwartze  operation, 
with  an  exposure  of  the  sigmoid 
sinus  and  the  dura  of  the  middle 
cerebral  fossa,  plate  XXXII,  316 

Cortex,  mastoid,  use  of  the  electric 
burr  for  opening  the,  271 ;  opening 
in  the  highest  point  of  the, 
253;  size  of  the  opening,  258;  re- 
moval of,  by  instruments,  254;  sur- 
face of  the,  appearance  of  the,  in 


416 


Index. 


mastoid  operation,  208;  varying 
thickness  of  the,  208 

Curette,  use  of,  for  removing  polypi, 
72 

Curetting,  for  opening  the  cortex,  254; 
in  after-treatment  of  mastoid  opera- 
tions, 398,  400,  403;  of  the  tympanic 
mucosa,  55,  56,  57;  raw  surfaces 
after  operations,  Bonain's  method  of, 
163;  removing  the  outer  attical  wall 
by,  143,  144,  145;  tympanic  walls 
after  ossiculectomy,  57 

D 

Degeneration,  fatty,  54 

Dench,  method  of,  for  removing  the 
incus,  123;  method  of,  for  removing 
the  malleus,  114,  113;  method  of,  in 
skin  grafting  after  radical  opera- 
tion, 310,  311,  312,  339,  340 

Dermal  flaps,  see  SKIN  FLAPS 

Destruction  of  the  long  process  of  the 
incus,  94 

Discharge,  purulent,  as  a  symptom  of 
the  pathological  conditions,  9;  cessa- 
tion of,  after  operation,  175;  from 
perforations  of  the  tympanic  mem- 
brane, 17;  irrigation  as  an  aid  to 
drainage  in,  402;  treatment  of,  after 
operations,  163-165 

Drain,  object  of  the,  in  after  treatment 
of  operation  through  the  canal,  172, 

173 

Drainage,  after  ossiculectomy,  167;  in 
chronic  otorrhcea  after  operation, 
401,  402;  wick,  281 

Dressing,  167,  274,  313,  314;  gauze 
drain  for,  after  ossiculectomy,  167; 
of  the  mastoid  wound,  changing  the 
first,  400, 401 ;  of  the  wound  after  sim- 
ple mastoid  operation,  274;  the  cav- 
ity after  radical  operation,  313,  314 

Dressings,  160,  167,  172,  313,  314,  400; 
after  operations,  172;  sterilization  of, 
in  mastoid  operations,  232 

"Drip  cup,"  the  antrum  as  a,  237 

Drum-membrane.  See  MEMBRANA 
TYMPANI 


Dura  mater,  avoiding  wounding  the, 
in  entering  the  antrum,  270;  granu- 
lation of  the,  61 

E 

Ear,  closing  of  the  opening  behind  the, 
in  mastoid  operation,  385,  386;  drum 
of  the,  enlargement  of  the  perfora- 
tion of  the,  46;  operation  for  dis- 
secting away  the  drum  of  the,  from 
inner  tympanic  wall,  53;  internal, 
plate,  XXI,  198;  middle,  after  treat- 
ment of  operations  on  the,  161,  162; 
anatomical  landmarks  as  related  to 
the  surgical  pathology  of  the  mid- 
dle, 10;  anatomy  of  the  middle, 
10-13;  caries  of  the  middle,  18; 
cholesteatoma  of  the  middle,  74; 
pathological  alterations  of  the  mid- 
dle, 19;  surgical  treatment  of  the 
middle,  68-131 

Eburnation  of  the  mastoid,  260 

Eczema  occurring  during  after-treat- 
ment of  mastoid  operations,  409 

Electric  burr,  advantages  of  the,  in 
opening  the  mastoid  cortex,  271 ; 
cooling  of  the,  to  avoid  necrosis,  34; 
for  grinding  down  osseous  tissue, 
319,  320;  for  leveling  down  the  facial 
spur,  320 

Empyema,  238 

Encapsulation  of  cholesteatomatous 
material,  14;  of  pus  cells,  14 

Epidermic  scales,  formation  of,  dur- 
ing the  after-treatment  of  mastoid 
operations,  409 

Epidermization,  in  limited  areas,  skin 
grafting  to  aid,  404,  405;  method  of 
producing  complete,  375,  376;  of  the 
cavity  after  the  radical  operation, 
405,  406;  of  the  cavum  tympani  after 
operation  via  auditory  canal,  346 

Epitympanic  regions,  curetting,  through 
the  canal,  145 

Epitympanum,  treatment  of  caries  of 
the,  135-154 

Eucain  as  a  local  anaesthetic,  39 

Eustachian   tube,   catarrh   of   the,   17; 


Index. 


avoiding  infection  of,  from  the  naso- 
pharynx, 404;  cleansing  of  nares  and 
nasopharynx  to  avoid  infection  of 
the,  169;  osseous  opening  of,  plate 
XX,  194;  sealing  mouth  of,  to  avoid 
infection  from  the  nasopharynx,  404 

Evisceration,  of  the  entire  affected 
mastoid  for  proliferation,  261 ;  of  the 
mastoid  and  tympanic  contents,  5 

Evulsion  of  polypi,  72 

External  cortex  of  the  mastoid  re- 
moved and  the  mastoid  antrum 
opened,  plate  XXVIII,  25 

External  surface  of  the  temporal  bone 
of  the  new-born  infant,  plate  XXII, 
204 

F 

Facial  nerve.    See  Facial  NERVE. 

Fallopian  and  external  semicircular 
canal  considered  in  relation  to  aural 
suppuration,  200,  201 

Fenestra  ovalis,  plate  XX,   194 

Fenestra   rotunda,   plate   XX.,    194 

Fistula  of  the  mastoid  process,  326 

Fistulous  openings,  cauterizing  the 
edges  of,  after  partial  healing  of  the 
mastoid  incision,  408 

Flaps,  skin,  308,  309 ;  Bench's  method  of 
forming,  339,  340;  making  of  Kuster, 
338,  339;  manipulation  of,  during 
mastoid  operation,  248 

Forceps-chisel,  removing  external  wall 
of  the  attic  with  the,  143,  144.  145 

Forceps,  cutting,  for  removing  granu- 
lation tissue,  62,  63 

Formaline,  solution  as  an  antiseptic 
in  after-treatment  of  operations,  161 

Fossa,  cerebral,  plate  I,  12;  glenoid, 
plate  XXII,  204 ;  middle  cerebral,  316 
(plate  XXXII)  ;  spine  of  Henle  in 
relation  to  middle  cerebral,  196;  cra- 
nial, avoiding  the,  in  mastoid  opera- 
tion, 226;  variation  in  depth  of,  224 

G 

Gauze  drain,  use  of,  after  ossiculec- 
tomy,  167;  drainage,  several  factors 

28 


to  be  remembered  in  using,  172,  173; 
to  stop  the  oozing  after  curettage, 
173 

Gellee's    modification   of   the   mastoid 
operation,  330 

Gold  leaf  to  prevent  adhesion  in  graft- 
ing, 405 

Gouge,  use  of,  in  removing  the  cortex 
in  mastoid  operation,  254 

Grafting,  345-390;  skin,  avoidance  of 
overlapping  in,  336;  care  in,  to  pre- 
vent impairment  of  hearing,  405; 
Dench  method  of,  in  after-treatment 
of  radical  operation,  310,  311;  in  Bal- 
lance's  mastoid  operation,  335 ;  Panse 
method  of,  347,  348;  parts  that  should 
be  especially  protected  in,  336;  to 
hasten  resolution  and  prevent  sup- 
puration, 404,  405 

Granulation,  of  the  tympanic  mucosa, 
56;  removing,  from  canal  or  tym- 
panic cavity,  37;  surgical  treatment 
of,  61 ;  tissue,  after-treatment  of,  in 
radical  operations,  403;  curetting  of, 
in  after-treatment  of  mastoid  opera- 
tions, 398;  exuberant,  lessening  the 
secretion  of,  161 ;  reduction  of,  by 
antiseptics  before  operation,  8;  re- 
moval of,  by  cutting  forceps,  62,  63; 
removing,  from  the  surface  of  the 
antrum,  13 

Granuloma  of  Prussak's  space,  62 
Grunert-Zeroni,  plastic  method  of,  365, 
366 

H 

Healing  after  radical  operation,  406; 
curetted  surfaces  with  boracic  acid, 
162;  of  the  wound  after  simple  mas- 
toid operation,  274 

Hearing  better  when  the  posterior 
wound  heals  from  the  bottom,  327; 
care  in  grafting  to  prevent  impair- 
ment of,  405 

Hemorrhage,  272-274;  control  of,  dur- 
ing simple  mastoid  operation,  247; 
control  of,  in  ossiculectomy,  104,  108, 
126;  control  of,  in  removing  the 


4i8 


Index. 


bone  in  the  region  of  the  sinus,  269, 
270;  control  of,  while  excavating  the 
mastoid  interior,  272;  from  stripping 
up  the  periosteum,  217;  treatment  of, 
from  the  wound  after  mastoid  opera- 
tion, 272-274;  venous,  during  simple 
mastoid  operation,  248 

Henle,  spine  of,  as  a  guide  for  opening 
the  mastoid,  192,  195;  as  a  land- 
mark, 216 ;  situation  of,  195 ;  varia- 
tion of  size  and  appearance  of,  195 

Herpes,  facial,  from  cauterizing  the 
mucosa,  57 

Hiatus  Fallopii,  plate  XX,  194 

Holmes'  measurements  of  the  antrum, 
199 

Hooks,  incus,  Ludwig*s,  125;  various 
forms  of,  123 

Hyperplasia  of  the  dermoid  layer,  54, 

55 

Hypertrophy  of  the  mucous  membrane 
of  the  antrum  and  mastoid  cells,  260 


Incudo-stapedial  joint,  cutting  away 
the,  before  removing  the  incus,  118 

Incus,  300,  plate  XXXI;  accidents  in 
removing  the,  126,  129;  Alderton's 
method  of  removing  the,  123 ;  caries 
of  the,  18,  22,  86,  90,  100;  Bench's 
method  of  removing  the,  123;  destruc- 
tion of  the,  98;  destruction  of  the 
long  process  of  the,  plate  XII,  94; 
hooks,  various  forms  of,  123 ;  Kretch- 
mann's  method  of  removing  the,  124 ; 
loss  of  topographical  position  of  the, 
90;  Ludwig's  method  of  removing  the, 
125;  methods  of  searching  for  the, 
120-125;  removal  of  the,  116-117;  re- 
moval of  the,  in  mastoiditis,  92,  119, 
120;  Zeroni's  method  of  removing 
the,  125 

Infiltration,  cell,  53,  54 

Instruments,  used  in  performing  ossic- 
ulectomy,  105;  sterilization  of,  for 
operation,  232,  397;  surgical  cleanli- 
ness of,  used  in  operations,  160 


Internal  surface  of  the  temporal  bone 
of  the  new-born,  plate  XXIII,  210 

Irrigation,  as  an  aid  to  drainage  in 
after  treatment  of  mastoid  opera- 
tions, 402;  of  the  wound  previous  to 
packing  after  radical  operation,  313; 
of  wounds  after  operation,  273 


Jansen-Stacke  flap  operation,  plate 
XXXV,  356;  plate  XXXVI,  358;  plate 
XXXVII,  360;  plate  XXXVIII,  362 

Joint,  incudo-stapedial,  cutting  away 
the,  before  removing  the  incus,  118; 
most  frequently  affected  in  chronic 
suppuration,  99 

K 

Kerrison,  statements  of,  relative  to  the 
depth  of  the  antrum,  199,  200 

Koerner,  flap  operation  of,  348,  353; 
modification  of,  354;  plate  XXXIII, 
350;  plate  XXXIV,  352;  technique 
of,  353,  3545  treatment  of  wound 
after  radical  operation,  395 

Kretchmann,  method  of,  for  removing 
the  incus,  124;  plastic  operation  of, 

364,  365 

Kuster  method  of  making  skin  flaps, 
338;  original  method  of  entering  the 
tympanum,  337 

L 

Large  perforation  of  the  drum  mem- 
brane, with  caries  of  the  handle  of 
the  malleus,  76,  plate  XI 

Lateral  sinus,  various  theories  as  to 
the  position  of  the,  221-224 

Lemoyez-Mahn  method  of  plastic  op- 
eration, 386,  387 

Leutert's  classification  of  chronic  sup- 
purative  otitis  media,  18 

Linea  temporalis,  as  a  landmark,  215; 
position  of  the,  216;  prominence  of, 
in  children,  216;  surgical  aspect  of 
the,  216 

M 

Macewen  triangle  as  a  point  of  election 
for  entering  the  antrum,  192 


Index. 


419 


Mahn-Lemoyez's  method  of  plastic  op- 
eration, 386,  389 

Malleus,  caries  of  the,  22,  86,  90;  ca- 
ries of  the  head  of  the,  18;  Bench's 
method  of  removing  the,  114,  115; 
detection  of  caries  of  the,  100; 
handle  of  the,  plate  XXII,  204;  re- 
moval of  incus  and,  for  free  drain- 
age in  attical  suppuration,  91 ;  re- 
moval of  the,  113-116 

Mastoid,  cavity,  cleansing  the,  before 
operation,  262,  263 ;  packing  the,  with 
iodoform  gauze  after  removal  of  os- 
seous tissue,  407;  cells,  plate  XX, 
194;  cells,  distribution  and  varia- 
tions of  the,  and  their  relation  to  sup- 
purative  otitis,  208 ;  cells,  hypertrophy 
of  the,  260 ;  changes,  238 ;  changes,  in 
children,  as  influencing  operation  in 
otitis  media,  267;  contents,  extent  of 
the  removal  of  the,  in  operation,  263, 
264;  fistula,  326;  formation  of  the, 
267,  268 

Mastoiditis,  acute,  237,  238,  259;  dur- 
ing tympanic  suppuration,  28 

Mastoiditis,  in  young  children,  267, 
268;  pathological  changes  in  the  tem- 
poral bone  in,  281 ;  removal  of  the 
incus  in,  92 

Mastoid  operation  (in  general),  after 
treatment  of,  393-410;  various  un- 
favorable local  symptoms  occurring 
during,  408,  409;  antiseptic  meas- 
ures in  after  treatment  of,  397 ;  avoid- 
ing the  middle  cranial  fossa  in  enter- 
ing the  antrum  in,  226;  drainage 
after,  401,  402;  facial  nerve  and  the 
lateral  sinus  in  relation  to  the,  25, 
200;  rule  for  general  anaesthesia  in, 
243;  importance  of  the  lateral  sinus 
in,  218;  indications  for,  100;  modifi- 
cation of,  325-341 ;  Panse  modifica- 
tion of  the,  328;  preliminary  prepara- 
tion of  the  patient  for,  229-233; 
Randall's  method  of  performing  the, 
202,  203;  Schleich's  local  anaesthesia 
in,  243;  source  of  danger  to  the 


facial  nerve  in,  25;  sterilization  of 
instruments  and  dressings  in,  232; 
upper  limits  of  the  field  of  the,  216; 
use  of  the  electric  burr  in  the,  271 
Mastoid  operation  (radical),  279-321; 
advantages  of,  for  tympanic  suppura- 
tion, 285;  after-treatment  0^393-410; 
care  of  patient  after,  400,  401 ;  car- 
nification  by  way  of  the  external  au- 
ditory meatus  after,  406;  choosing 
the,  from  a  pathological  aspect,  241 ; 
closing  the  incision  after,  312,  313; 
curetting  in  the,  303,  304;  differentia- 
tion of  opinion  as  to  audition  after 
the,  394;  disadvantages  that  may 
militate  against  the,  286;  facial  par- 
alysis after,  317;  facial  paresis  oc- 
curring during  after-treatment  of, 
410;  general  conditions  which  indi- 
cate, 281,  282;  impairment  of  hear- 
ing after,  286;  importance  of  the 
facial  nerve  and  the  external  semi- 
circular canal  in  the,  314;  in  caries 
of  the  antrum  associated  with  choles- 
teatoma,  96;  indications  for,  241, 
242,  280-282;  Kuster's  modification 
of  the,  337,  338;  making  the  opening 
through  the  cortex  in,  222;  modifica- 
tion of,  when  cholesteatomous  masses 
are  found,  318,  319;  object  of  main- 
taining the  retro-auricular  opening 
in  the,  362,  363;  objects  of  the,  285; 
packing  the  cavity  after,  313,  314; 
pain  on  change  of  dressing  after, 
3J3>  3J4;  plastic  method  after,  for 
covering  the  bone  surfaces,  308;  pri- 
mary union  in  the,  366,  367 ;  removal 
of  diseased  tissue  in,  306;  retro- 
auricular  opening,  maintenance  of 
the,  in,  385;  retro-auricular  opening, 
problematical  value  of  the,  in,  367; 
success  of  the,  depending  upon  the 
cavities  being  kept  free  from  in- 
fection, 304;  technique  of  skin  graft- 
ing in,  310,  3".  312;  time  required 
for  the  process  of  healing  after  the, 
408;  variation  in  the  treatment  of 


420 


Index. 


the  opening  in  the,  367;  various 
methods  of  closing  the  incision  in, 
312,  313;  Waring's  method  of  filling 
in  the  opening  behind  the  ear  after, 
340;  when  to  close  the  retro-auricu- 
lar opening  in  the,  385,  386;  Zaufal 
method  of,  287 

Mastoid  operation  (simple),  237-276; 
a  basis  for  the  radical  operation,  238, 
239;  after-treatment  of  the,  396,  397, 
398;  Blake's  treatment  of  the  wound 
after,  274;  completed,  on  a  bone 
specimen,  266,  plate  XXIX;  con- 
trol of  hemorrhage  during,  247, 
248;  curetting  tympanic  cavity  be- 
fore, 263;  difference  of  opinion  in 
regard  to  the  Schwartze  method  for, 
239;  dressing  the  wound  after  the, 
273,  274,  397;  healing  of  the  wound 
m>  397!  indications  for  the,  241,  242; 
manipulation  of  flaps  in,  248;  mean- 
ing of  the  term,  238;  object  of  the, 
238;  opening  of  the  antrum  in,  239; 
primary  incision  in,  244,  247,  250, 
plate  XXVII ;  removing  the  cor- 
tex in,  254;  retro-auricular  incision 
in,  244,  245,  plate  XXVI;  time 
required  for  the  process  of  healing 
after  the,  408;  treatment  of  the 
wound  after,  272,  274;  variation  of 
opinions  as  to  results  in  curing  otor- 
rhcea  by  the,  275;  use  of  the  chisel 
in,  254 

Mastoid  process,  classification  of  the, 
207,  208,  209;  diploetic  character  of, 
plate  XXV,  220;  eburnation  of  the, 
260;  eburnated  type  of,  rule  for  re- 
moving the  bone  of,  in  operation,  226 ; 
pneumatic  type  of  the,  207,  208; 
sclerotic  changes  of  the,  326;  scle- 
rotic type  of  the,  208 ;  site  for  entering 
the,  191,  192;  structure  of  the,  in  re- 
lation to  the  temporal  bone,  207; 
variation  of  the  pathological  changes 
in  the,  259;  vascular  association  of 
the  cranial  contents  and  the,  217; 
venous  relations  of  the  tympanic 
regions  and  the,  217 


Membrana  tympani,  adhesions  between, 
and  the  inner  tympanic  wall,  14; 
after-treatment  of  operations  on  the, 
!58,  159;  enlarging  the  perforations 
in  suppuration  of  the,  44,  45 ;  indica- 
tions for  second  perforation  of,  46; 
perforations  of  the  anterior  segment 
of,  17;  technique  of  operation  for 
perforation  of,  44;  posterior  perfora- 
tions of  the,  17;  removal  of  adhe- 
sions between  the  tympanic  wall  and 
the,  46;  removal  of,  for  adhesions, 
53;  sterilizing  the  canal  in  operation 
in  the,  44;  surgical  importance  of 
perforations  of,  18;  treatment  of 
perforations  of  the,  44;  thickening 
of,  in  long-standing  suppuration,  54 

Membrane,  drum,  retracted,  plate  VI, 
50;  plate  VIII,  60;  see  MEMBRANA 
TYMPANI;  caries  of  Shrapnell's,  86, 
87;  difficulty  in  locating  minute  per- 
forations in,  21 ;  perforation  in,  plate 
X,  70 

Meninges,  exposure  of  the,  during  op- 
eration for  chronic  otorrhoea,  270 

Meningitis  developing  from  an  ab- 
errant pneumatic  cell,  215 

Modification     of     mastoid     operations, 

325-341 

Moorhof-Mosetig  plastic  operation, 
plate  XLII,  378;  plate  XLIV,  382; 
plate  XLV,  384 

Morbid  changes,  in  eighty  consecutive 
cases  where  the  radical  operation 
was  performed,  305,  306;  in  the  mu- 
cosa,  53 

Mosetig-Moorhof  plastic  operation, 
plate  XLII,  378;  plate  XLIII,  380; 
plate  XLIV,  382;  plate  XLV,  384 

Mucosa,  granular  changes  in,  55-57; 
morbid  changes  in  the,  53,  54;  reten- 
tion of  pus  by  the  folds  of  the,  19 

Muscle,  stapedius,  cutting  the  tendon 
of  the,  119,  126,  127 

N 

Necrosis,  local  anaesthesia  in  exploring 
for,  in  the  external  auditory  canal, 


Index. 


421 


26;  of  the  tympanic  walls,  151;  su- 
perficial, in  chronic  suppuration,  152 
Nerve,  facial,  300,  plate  XXXI;  and 
the  lateral  sinus  in  relation  to  mas- 
toid  operation,  200;  and  the  spina, 
distance  separating  the,  206;  angle 
of  the,  in  adults,  205 ;  course  of  the, 
200,  201 ;  danger  to,  in  mastoid  op- 
erations, 25 ;  descent  of  the,  205 ; 
exposed,  plate  I,  12;  in  young  chil- 
dren, 205 ;  local  inflammation  of, 
after  cauterization  of  the  mucosa,  57 ; 
paralysis  of  the,  during  the  after- 
treatment  of  mastoid  operations,  410; 
position  of  the,  203,  206,  207 ;  protect- 
ing the,  in  radical  mastoid  operation, 

3M 

Normal  temporal  bone  with  a  pro- 
nounced convexity  of  the  mastoid 
process,  plate  XVIII,  184 


Obliteration  of  all  cavities  in  radical 
operations,  307 

Operation,  intratympanic,  anaesthesia  in, 
38;  of  synechiotomy  for  evacuation 
of  pus,  66 

Operations,  by  way  of  auditory  canal, 
object  of,  56;  mastoid.  See  MAS- 
TOID OPERATIONS  ;  preliminary  prep- 
arations of  the  patient  for,  35-39; 
through  the  external  auditory  canal, 
cardinal  principles  in  the  after-treat- 
ment of,  159 

Osseous,  cavity,  watching  the,  in  after- 
treatment  of  radical  operation,  320; 
walls,  applying  flaps  to  the,  after 
radical  operation,  308-310;  walls, 
treatment  of,  after  curetting,  170 

Ossicles,  and  attic  plates,  12;  calcifica- 
tion of  the,  101 ;  facial  paralysis  in 
removal  of  the,  129;  removal  of.  See 
Ossiculectomy ;  the  treatment  of 
the,  85-131 ;  Vacher's  method  of  re- 
moving the,  128 

Ossicular  landmarks,  localizing  accu- 
rately, 13 


Ossiculectomy,  accidents  liable  in,  126, 
129;  adrenalin  chloride  as  a  haemo- 
static in,  104 ;  anaesthesia  in,  102,  103 ; 
certain  limitations  of,  97;  cessation 
of  discharge  after,  175;  contraindica- 
tions for,  19;  control  of  hemorrhage 
in,  126;  essentials  for  successful  re- 
sults in,  7,  8;  final  results  (as  to 
amelioration  or  cure)  of,  in  sup- 
puration, 130,  131 ;  first  step  in,  106- 
108;  for  free  drainage  in  attical  sup- 
puration, 86, 88, 91 ;  gauze  drain  after, 
167;  general  anaesthesia  in  perform- 
ing, 38,  39;  general  constitutional 
treatment  after,  174;  in  attical  sup- 
puration, 86;  indications  for,  in  at- 
tical suppuration,  86-97;  inflamma- 
tory symptoms  following,  175;  pain 
from  blood  clots  after,  173,  174; 
Politzer's  classification  of  conditions 
for  performing,  96;  technique  of, 
102;  variation  in  the  technique  of, 
to  suit  different  conditions,  101 
Osteitis,  chronic  proliferative,  259 
Otitis  media,  chronic  suppurative,  ad- 
vantages of  operation  by  way  of  the 
auditory  canal  for,  6;  associated  with 
impairment  of  the  hearing,  130;  Bal- 
lance's  operation  for,  333,  334;  caries 
in>  305 ;  formaline  solution  in  treat- 
ment of,  166;  formation  of  new  bone 
in,  259;  treatment  of,  by  simple  mas- 
toid operation,  267;  intratympanic 
operation  for,  6;  Leutert's  classifica- 
tion of,  18;  operative  treatment  of, 
through  the  post-auricular  route,  182 ; 
Ossiculectomy  in,  92;  pathological 
changes  in,  237;  permanent  cure  for, 
6;  Politzer's  indications  for  opening 
the  mastoid  in,  240,  241 ;  removal  of 
polyps  with  forceps  in,  78;  removal 
of  the  incus  in,  92;  Schwartze's 
operation  in,  240,  241;  Stacke- 
Schwartze  operation  in,  293;  treat- 
ment of,  after  operation,  165,  393; 
when  to  open  the  mastoid  in,  240, 
241 


422 


Index. 


Otorrhcea,  8,  9,  140,  318,  401,  402; 
chronic,  avoiding  the  exposure  of 
the  lateral  sinus  in  operation  for, 
318;  condition  of  the  antrum  in,  305; 
drainage  in,  after  operation,  401,  402; 
dressing  the  wound  after  mastoid  op- 
eration for,  273;  facial  palsy  in,  80; 
indications  for  operation  in,  85,  86; 
loss  of  the  incus  in,  120;  removal  of 
polypi  and  granulation  tissue  in,  73; 
variation  of  opinion  in  curing,  by 
the  simple  mastoid  operation,  275 ; 
from  infection  of  the  nasopharynx 
after  operation,  304;  odor  of  dis- 
charge in,  9;  preliminary  treatment 
of,  9 

P 

Packing.    See  TAMPONING 

Pain  after  ossiculectomy,  blood  clots 
the  cause  of,  173,  174;  Ballance's 
modification  of  the  mastoid  operation 
to  avoid,  334;  in  change  of  dressing 
after  radical  operation,  313,  314;  mas- 
toid, an  indication  for  radical  opera- 
tion, 282;  relief  of,  in  chronic  sup- 
puration, 80;  syringing  after  opera- 
tions for,  164 

Panse,  method  of  grafting,  347;  modi- 
fication of  mastoid  operation,  328 

Paralysis,  facial,  after  mastoid  opera- 
tion, 317;  from  too  forcible  use  of  the 
the  incus  hook,  125,  129 

Paresis,  facial,  occurring  during  after- 
treatment  of  mastoid  operations,  410 

Partially  completed  Stacke-Schwartze 
operation,  plate  XXXI,  300 

Passow,  plastic  operation  of,  365 

Passow-Trautmann  plastic  operation, 
plate  XXXIX,  370;  plate  XL,  372; 
plate  XLI,  374 

Perforation,  into  the  tympanic  mem- 
brane, after-treatment  of,  158 

Perforations,  and  their  significance,  18, 
19;  minute,  difficulty  in  locating,  in 
Shrapnell's  membrane,  21 ;  surgical 
treatment  of,  in  the  membrana  tym- 
pani,  44 


Periosteum,  stripping  of  the,  hemor- 
rhage from,  217;  treatment  of,  dur- 
ing simple  mastoid  operation,  247; 
treatment  of,  in  the  Stacke  opera- 
tion, 289,  290,  296 

Peroxide  of  hydrogen  treatment  to 
control  pus  formation,  171 

Physiological  salt  solution  in  irriga- 
tion of  wound  after  mastoid  opera- 
tion, 273,  410 

Plastic  flap  methods,  345-390 

Politzer's,  classification  of  conditions 
that  specially  indicate  ossiculectomy, 
96;  classification  of  the  local  causes 
of  caries  of  the  tympanic  walls,  147; 
methods  in  plastic  operation,  389, 
390 

Polyp,  aural,  plate  X,  70;  formation, 
77;  cauterizing  the  base  of,  after  re- 
moval, 68;  different  methods  of  re- 
moving, 71-74;  in  chronic  tympanic 
suppuration,  66,  67 ;  multiple,  removal 
of,  with  forceps,  78;  removal  of,  by 
cold  or  hot  snare,  67;  removal  of, 
from  the  tympanic  roof,  68;  remov- 
ing, from  canal  or  tympanic  cavity, 
37;  surgical  treatment  of,  61,  67 

Preliminary  preparation  of  the  patient 
for  operation,  35-39 

Primary  incision  carried  through  the 
skin  and  periosteum,  soft  parts  re- 
tracted, showing  underlying  bone,  and 
field  of  operation,  plate  XXVII,  250 

Probe,  caution  in  using  the,  in  lesions 
of  the  tympanic  walls,  136,  137;  use 
of  the,  in  locating  carious  areas,  145 ; 
use  of  the,  in  reaching  the  antrum, 

251 

Prussak's  space,  14;  granuloma  of,  62 
Pus,  cells,  encapsulation  of,  14;  course 
of,  from  antrum  and  mastoid  cells, 
95;  course  of,  from  the  attic,  95; 
course  of,  in  suppuration  of  the  tym- 
panic walls,  142;  retention  of,  by 
folds  of  the  mucosa,  19;  secondary, 
collections,  399;  synechiotomy  for 
evacuation  of,  66 


Index. 


423 


R 

Radical  mastoid  operation.  See  under 
MASTOID  OPERATIONS. 

Randall's  method  in  performing  radical 
operation,  340;  theory  in  regard 
to  the  lateral  sinus  and  its  surround- 
ings, 218 

Reinhart  method  of  plastic  operation, 
376 

Retractors,  use  of,  in  mastoid  opera- 
tion, 248 

Retro-auricular  opening  after  radical 
operation,  keeping  the  wound  free 
by,  313;  and  plastic  operations,  345- 
390 

Ridge,  temporal.  See  LINEA  TEMPOR- 
ALIS 

s 

Sagittal  section  of  the  mastoid  proc- 
ess and  tympanic  cavity,  plate  XIX, 
188;  on  a  plane  with  the  facial  nerve, 
plate  XX,  194 

Scales,  epidermic,  formation  of,  dur- 
ing the  after-treatment  of  mastoid 
operations,  409 

Schematic  drawing  of  the  removal  of 
the  malleus,  with  the  forceps  in  po- 
sition, plate  XIV,  no;  of  the  in- 
cus, after  the  completion  of  the  re- 
moval of  the  malleus,  plate  XV,  117; 
side  view  of  the  tympanic  cavity 
showing  an  adhesive  process  between 
the  drum  membrane  and  promontory, 
51 ;  retracted  cicatrix  and  intra-tym- 
panic  relations,  plate  V,  48;  tympa- 
num showing  necrosis  of  the  handle 
of  the  malleus  and  a  polypus,  119; 
view  of  the  tympanum  illustrating 
cutting  of  adhesions  between  the 
promontory  and  drum  membrane, 
plate  VII,  52;  showing  necrosis, 
plate  XVII,  138;  Schwartze  operation 
in  distinction  to  the  radical,  239 

Schwartze-Stacke,  the,  operation.     See 

SXACKE-SCHWARTZE   OPERATION. 

Sequestrum  of  bone,  removal  of,  from 
the  tympanic  cavity,  152,  153 


Shrapnell's  membrane,  perforation  of, 
14,  17,  170,  plate  X 

Siebermann,  plastic  method  of,  364 

Silver  salts  in  after-treatment  of  opera- 
tions, 160,  166 

Sinus,  lateral,  abnormalities  in  position 
of,  221,  222;  accidental  opening  of 
the,  in  chronic  suppuration,  268;  and 
the  facial  nerve  in  relation  to  mastoid 
operation,  200;  asymmetry  of  the 
skull  as  a  cause  for  displacement  of 
the,  223,  224;  dangerous  area  of  the, 
222;  guiding  rule  for  avoiding  the 
opening  of  the  sinus  in  mastoid  op- 
eration, 269 ;  methods  for  locating  ac- 
curately the,  223;  normal  position 
of  the,  221 ;  variation  in  size  and  po- 
sition of  the,  218 

Sinus,  sigmoid,  316,  plate  XXXII 

Skin  flaps,  308,  327;  making  of  Kuster, 
338,  339 

Skin,  irritation  of  the,  during  after 
treatment  of  mastoid  operations,  409 ; 
transplantation,  310-312,  327 

Skull,  asymmetry  of  the,  223,  224 

Snare,  cold,  for  removing  polypi,  67; 
hot,  for  removal  of  polypi,  67 

Space,  hypotympanic,  situation  of,  13; 
Prussak's,  14;  granuloma  of,  62 

Spina  and  facial  nerve,  distance  sep- 
arating the,  206 

Spine,  of  Henle,  as  a  landmark,  216 ;  in 
relation  to  the  middle  cerebral  fossa, 
196;  variation  of  size  and  appear- 
ance of,  195-196;  suprameatal,  as  a 
guide  for  opening  the  mastoid,  192, 
195;  situation  of,  195 

"  Spongy  spot,"  191,  225 

Squamous  plate,  plate  XXII,  204 

Stacke-Jansen  flap  operation,  plate 
XXXV,  356;  plate  XXXVI,  358;  plate 
XXXVII,  360;  plate  XXXVIII,  362 

Stacke  operation,  advantages  of,  in 
radical  mastoid  operation,  287,  288; 
after-treatment  of,  399;  disadvan- 
tages of  the,  288;  primary  step  in 
the,  289,  290;  special  indications  for, 
288;  technique  of,  292,  293 


424 


Index. 


Stacke,  plastic  methods  of,  363,  364 

Stacke-Schwartze  operation,  284,  plate 
XXX;  advantages  of  the,  292,  293; 
care  of  the  patient  after  the,  400, 
401 ;  eradication  of  the  cause  of 
otitis  media  by  the,  293;  in  choleste- 
atoma,  289;  modification  of  the  pri- 
mary incision  of,  295;  primary  in- 
cision over  the  mastoid  in,  293,  294, 
295 ;  technique  of  the,  292-295 ;  treat- 
ment of  the  periosteum  in  the,  296 

Stapes,  300,  plate  XXXI ;  danger  of  re- 
moving the,  in  suppurative  condi- 
tions, 127,  128;  operative  procedures 
on  the,  126,  127 

Suppuration,  attical,  22,  86;  chronic, 
Bergmann's  operation  indicated  in, 
331 ;  division  of,  into  three  classes, 
97;  relief  of  pain  in,  80;  skin  grafting 
to  hasten  resolution  and  prevent, 
404,  405;  Stacke  or  Zaufal  operation 
in,  259;  use  of  the  chisel  in  opening 
the  antrum  for,  268-270;  Stacke's 
method  for  the  radical  cure  of,  287; 
mastoid,  when  to  operate  on,  280 

Suprameatal  spine,  as  a  guide  for  open- 
ing the  mastoid,  192,  195 ;  as  a  land- 
mark, 186;  situation  of,  195 

Suture,  squamo-mastoid,  importance  of 
as  a  landmark,  215 ;  locating  the,  215 

Suturing  the  incision  after  mastoid 
operation,  273,  274,  312 

Synechiotomy  for  evacuation  of  re- 
tained pus,  66 

Syringing  for  removing  debris  and  pur- 
ulent secretions  from  the  ear  after 
operation,  163;  indications  for,  in 
pain  after  operation,  164 


Tamponing,  injury  to  the  facial  nerve 
from  too  tight,  317;  mouth  of  Eu- 
stachian  tube  to  avoid  infection  from 
the  nasopharynx,  404;  the  mastoid 
cavity  after  radical  operation,  313, 
314,  401,  405 

Tegmen  tympani,  plate  I,  n,  12 


Temperature,  elevated,  after  mastoid 
operations,  410;  in  after-treatment 
of  mastoid  operations,  399 

Temporal  bone,  cerebral  surface  of 
the  petrous  portion  of  the,  plate  XX, 
194;  topography  of  the,  224;  varia- 
tion of,  in  the  child  from  that  of  the 
adult,  224 

Tenotomy  of  the  tendon  of  the  tensor 
tympani  muscle,  in,  112 

The  after-treatment  of  operations 
through  the  external  auditory  canal, 
IS7-I76 

The  radical  mastoid  operation,  279-321 

The  retro-auricular  opening  and  plas- 
tic methods,  345-390 

The  simple  mastoid  operation,  237-276 

The  treatment,  of  caries  of  the  tympanic 
walls,  the  epitympanum  and  hypotym- 
panum,  135-154;  of  the  mucosa  and 
muco-periosteum  of  the  tympanic 
cavity,  43-81 ;  of  the  ossicles,  85-131 

Thiersch's  grafts,  346,  406 

Tissue  granulation,  after-treatment  of, 
in  radical  operations,  403;  curetting 
of,  58,  398;  removal  of,  by  cutting 
forceps,  62,  63 

Tissues,  cauterizing  the,  of  the  tym- 
panic cavity,  65,  66 

Transplantation  of  skin,  310-312 

Trautmann  plastic  operation,  tech- 
nique of  the,  387,  388 

Trautmann-Passow  plastic  operation, 
plate  XXXIX,  370;  plate  XL,  372; 
plate  XLI,  374 

Triangle,  Macewen's,  as  a  guide  for 
opening  the  antrum,  192 

Tube,  Eustachian.  See  EUSTACHIAN 
TUBE 

Tympanic,  cavity,  plate  V,  48;  anatomy 
of,  10 ;  care  of  nose  and  nasopharynx 
as  after-treatment  of  operation  on  the 
169;  cleansing  the,  after  evisceration, 
169;  cleansing  the,  with  the  curette, 
303 ;  curetting  of,  diversity  of  opinion 
in  regard  to,  56,  57;  pathological 
changes  in  the,  101 ;  removal  of  se- 
questrum of  bone  from  the,  152, 


Index. 


425 


!53;  ring,  examination  of,  after  cu- 
retting, 153;  walls,  caries  of,  6,  152; 
caries  of  the,  treatment  of,  140, 141 ; 
causes  of  caries  of  the,  147 ;  curetting 
of  the,  150,  151;  curetting,  after  os- 
siculectomy,  57;  curettage  and  ex- 
cision of,  for  caries,  6;  diagnosis  of 
caries  in  the,  136-139;  indications  for 
operative  procedures  on  the,  139 ; 
indications  for  removing  caries  from 
the,  147,  148;  lactic  acid  applications 
to,  after  operations,  171 ;  lesions  of 
the,  care  in  using  the  probe  in,  136, 
139;  smoothing  the,  in  radical  opera- 
tion, 307;  thickening  of  the  walls  of 
the,  149;  operation  for  detaching  ad- 
herent membrane  from  the,  53 
Tympanum,  caries  of  the,  character- 
istics of,  141,  142;  cholesteatoma  of 
the,  79 ;  floor  of  the,  situation  of,  13 ; 
indications  for  treatment  of  the,  29; 
osseous  changes  in  the,  148,  149; 
removing  the  stapes  in  suppurative 
conditions  of  the,  127;  roof  of,  sur- 
gical relations  of  the,  20;  roof  of,  in 
chronic  suppuration,  10;  venous  re- 
lations of  the  mastoid  process  and 
the,  217 


V 

Vacher,  method  of  removing  the  ossi- 
cles, 128 

Vein,  mastoid  emissary,  bleeding  from 
severing  the,  in  mastoid  operation, 
217 

Vertigo,  labyrinthine,  radical  mas- 
toid operation  in,  282 

w 

Wall,  post  meatal,  care  in  removing 
the,  317 

"  Wick  drainage,"  281 

Wound,  dressing  of  the,  after  simple 
mastoid  operation,  273,  274;  dress- 
ing of,  after  the  radical  operation; 
394-401 

Z 

Zaufal-Kuster  method  of  opening  the 
antrum,  328;  method  compared  with 
Stacke-Schwartze  in  removing  os- 
seous tissue,  328;  method  of,  in 
radical  mastoid  operation,  287 

Zeroni,  method  of,  in  removing  the 
incus,  125;  -Grunert,  plastic  method 
of,  365,  366 

Zone,   vascular,   variation   of  the,    191 

Zygomatic  process,  plate  XXII,  204 


Oppenheimer  ,  Seymour 


Sxirgical  treatment  of  chronic 
suppuration  of  the  middle  ear  and 
mastcid 

MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

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